Child Sexual Abuse/Assault Workshop. Jan Wiebe RN, SANE-P Angel Stegner MSW Lisa S. Spector MD

Transcription

1 Child Sexual Abuse/Assault Workshop Jan Wiebe RN, SANE-P Angel Stegner MSW Lisa S. Spector MD

2 CC: Blood in Underwear CASE 1 HPI: A previously healthy 3 yr old female presents to ED at 5:00 pm on Monday with step-mom and PGM for blood in underwear.

3 Step-mom said she took pt to toilet around 3:00 pm today and noted a few spots of bright red blood in underwear. Bio-parents are divorced. Pt spent the weekend with PGPs (Friday 8:00 pm until 10:00 am Monday). Step-mom and dad took pt to park from 11:00 am until 12:30 pm. 1:00 pm Step-mom and pt colored. 2:00 pm Step-mom gave pt a bath. She left pt in bathtub to clean up and returned to bathtub when she heard her crying. She got her dressed and noticed the blood in underwear around 3:00 pm when she was helping her use the toilet. Step-mom has not seen her underwear earlier in the day today, her dad changed her earlier in the day (he left for work at 2:00pm).

4 Which of the following would not lead to blood in underwear? A. Urethral Prolapse B. Vulvovaginitis C. Pinworms D. Foreign Body E. All of above can cause blood in underwear

5 Urethral Prolapse Cause Unknown Symptoms Pain, bleeding, burning Treatment Topical Steroids Topical Estrogen cream Surgery

6 Minor Trauma Scratching Pinworms Masturbation Rarely cause injury Clitoris or Labia

7 Infections Dermatitis- vulvitis: Candida Albicans GABH Strep Staph Aureus Hemophilus influenza CULTURE! CULTURE! CULTURE! Vaginitis: Staph Aureus GABH Strep Shigella, Salmonella, Yersenia, E. Coli

8 Foreign Body Toilet tissue Toys/objects *Must Irrigate with Sterile Normal Saline

9 Genital Exam A. Normal Vulva B. Abnormal Vulva C. Indeterminate Vulva

10 Digression Tips for doing a good anogenital exam

11 Describe all findings in relation to the clock

12 Examination techniques Labial separation Labial traction Lateral decubitus Prone knee-chest Cannon Ball

13 Labial separation Hymenal rim difficult to visualize

14 Labial traction Better visualization of hymenal rim

15 If you pull apart you put strain on the posterior Fourchette causing pain

16 Patience Labial Manipulation

17 Prone knee-chest position Good position to confirm clefts Can examine vaginal vault for foreign bodies NOT intimidating for a child

18 Prone Cervix in prepub Foreign Body

19 Lateral decubitus position Good position for collecting anal samples Limited visualization of anal structures

20 Cannon Ball

21 Techniques Saline Swab Foley catheter Vaginal Irrigation

22 If intra-vaginal septum needs a Pelvic Ultrasound to ensure NO septum of vagina or other reproductive organs

23 Catheter Technique to see Redundant Hymen

24 Back to our Patient

25 Anal Exam A. Warts B. Molluscum Contagiosum C. Skin Tags

26 When no gross blood noted on anogenital exam we must A. Perform a Urinalysis B. Guiac Stool C. Culture Vaginal Vault D. Consider irrigating Vaginal Vault E. All of the above

27 Vaginal Irrigation Supplies Sterile Water/ Normal Saline 60 cc Luer Lock syringe KY jelly 8 french feeding tube Absorbent Pad

28 Anogenital warts on a child 3 yr of age or younger are A. Diagnostic of Child Sexual Abuse/Assault B. Not concerning for Child Sexual Abuse/Assault C. Suspicious for Child Sexual Abuse/Assault D. None of the above

29 Human Papiloma Virus If not perinatally acquired and rare nonsexual vertical transmission is excluded it is Suspicious for CSA

30 Human Papilloma Virus DNA virus >100 types affecting epithelium (cutaneous or mucosal) Skin: Type 1-4, 7,10 (common, plantar, flat) Anogenital: 6 & 11 (16, 18, 31, 35) OP: 6, 11, 16, 18 *Cutaneous types documented in anogenital sites Incubation: 3mo - several years

31 HPV: Transmission Sexual Contact (genital-genital, oral-genital, digital-genital) Non-Sexual Contact (digital-genital) Diaper Changing/Toileting Perinatally Genital warts Abnormal Pap Autoinoculation Inanimate Objects??

32 HPV: Transmission Direct contact between fully formed virions and the lowest basal cells of the epithelium, presumably through microfissures. Most HPV infections develop in areas exposed to physical trauma: introitus, anus, feet and hands Most frequent site of HPV infection in women is the tranformation zone: basal cells at the squamocolumnar jxn locus for direct virus-cell contact w/o physical trauma

33 A biopsy to Type the wart can help distinguish sexual transmission from non-sexual transmission? A. True B. False

34 Bx: HPV typing not Helpful High prevalence of subclinical infection Multiple HPV types coexist in same individual Cutaneous wart: sexual or non-sexual contact HPV 6/11 very common Same type in child/adult: sexual or non-sexual

35 A hotline needs to be made to CPS in this case because A. Child has blood in underwear B. Child was left unattended in bathtub C. Child has anogenital wart D. None of the above E. Both B and C

36 AAP definition of Supervisory Neglect When a caregiver s supervisory decisions or behaviors place a child in his/her care at significant ongoing risk for physical, emotional or psychological harm.

37 CC: Sexual Assault Case 2 HPI:A 14 year old female presents with her mother. The mother is upset because she has just found out that her daughter has had sexual intercourse with a 20yo male, which the daughter claims is consensual. The mother of the patient is demanding that a Rape Kit be done and she wants to file charges with the police

38 Is a 14 year old female able to consent to sexual intercourse with a 20 year old male in a. Missouri b. Kansas c. Neither State d. Both States

39 Missouri Law Legal Age of Consent is 17 years of age NO ONE under the age of 14 can legally consent to sexual intercourse under any circumstances. Missouri law has a provision where persons age years of age can consent to have sexual intercourse with someone else if that other person is years of age

40 Kansas Law Legal Age of Consent is 16 years of Age Romeo and Juliet Law (K.S.A ) penalty for statutory rape is less severe when the case involves. two teenagers. When one is years of age and the offender is <19 years of age the age difference is three years the child and the offender are the only parties involved and are members of the opposite sex.

41 What is a SANE Sexual Assault Nurse Examiner A. is a Registered Nurse who has extensive specialized training in caring for victims of sexual assault. B. collects forensic evidence, identifies and records injuries from the assault/abuse and recommends additional services. C. diagnoses sexual abuse/assault D. A and B

42 SANE-A Adolescent and Adult 40 hours of didactic coursework Clinic Preceptorship under the guidance of a physician, advance practice nurse of forensically experienced registered nurse International association of Forensic nurses (IAFN) offers national certification exam

43 SANE Program At CMH 11 SANEs We see patients through the downtown ED and South Urgent Care Hours of operation All of our cases are reviewed by one of our Child Abuse Pediatricians

44 Process at CMH Patient presents to CMH Emergency Dept. or South Urgent Care Center Triaged to ensure medically stable Social Worker notified and child at risk assessment done Decision made as to whether patient is acute or non-acute

45 ACUTE vs. NON-ACUTE

46 ACUTE Presents within a set time frame for evidence collection Presents with signs of trauma and/or anogenital pain and/or bleeding There are immediate safety concerns If patient is acute the SANE is activated

47 NON-ACUTE Presents outside the time frame for evidence collection No signs of trauma and/or anogenital pain and/or bleeding There are immediate safety concerns If non-acute the patient needs to have a medical exam, but a forensic interview is arranged prior to exam

48 General purposes of the Exam Medical: Assess and treat the medical health consequences of sexual abuse or assault Forensic: gather information and materials that assist Law enforcement in their investigation Therapeutic: Providing appropriate recommendations for additional services

49 Which of the following are true regarding STI testing of adolescent SA victim? A. NAATs for C. trachomatis and N. gonorrhoeae. These tests are preferred for the diagnostic evaluation of sexual assault victims, regardless of the sites of penetration or attempted penetration. B. Wet mount and culture or point-of-care testing of a vaginalswab specimen for T. vaginalis infection. The wet mount also should be examined for evidence of BV and candidiasis, especially if vaginal discharge, malodor, or itching is evident. C. A serum sample for immediate evaluation for HIV infection, hepatitis B, and syphilis. Decisions to perform these tests should be made on an individual basis. D. All of the above.

50 How is this different from Prepubertal Victims?

51 N. gonorrhoeae Culture Pharynx and Anus - boys and girls Culture Vagina- girls, Culture Urethra boys (meatus if d/c present) *Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines MMWR Vol 55 (no RR-11) 1-93, 2006

52 C. trachomatis Culture Anus boys and girls Culture Vagina girls Not Urethra of boys (likelihood of recovering from the urethra of boys is too low to justify urethral swab swam meatus if d/c present) Pharyngeal not recommended yield is low Lab not distinguish between C. trachomatis and C. Pneumoniae

53 What about NAATs? NAATs can be used for detection of C. trachomatis or N. gonorrhoeae in vaginal specimens or urine from girls. All specimens should be retained for additional testing if necessary. No data are available regarding the use of NAATs in boys or for extragenital specimens (e.g., those obtained from the rectum) in boys and girls. Culture remains the preferred method for extragenital sites.

54 Which of the following are true regarding testing/treating for STIs after sexual abuse/assault? A. All prepubertal victims should be tested for STIs. B. All adolescents victims should receive STI prophylaxis. C. All prepubertal victims should receive STI prophylaxis.

55 Strong indication for Testing Child with sx/sy of STI or an infection that can be sexually transmitted, even in the absence of suspicion of CSA (sx: vag d/c or pain, genital itching or odor, urinary sy, genital ulcers or lesions) Suspected assailant known to have STI or to be high risk (mult sex partner, h/o STI) or unknown history Sibling or other child/adult in house/environment has and STI Patient/Parent/Family requests testing Evidence of genital, oral or anal penetration or ejaculation is present. Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines MMWR Vol 55 (no RR-11) 1-93, 2006

56 Prophylaxis Not recommended for sexually abused child Incidence of STIs is low Risk of spread to upper genital tract for girls is low Follow-up usually can be insured (CPS/LE)

57 Which is true regarding emergency contraceptive pills Plan B and Next Choice? A. Plan B and Next Choice are progestin only pills B. Both pills of Plan B can be given at once (1.5 mg of Levonorgestrel). Same as Plan B One Step. C. Human and animal data show it works by delaying or inhibiting ovulation (there is no post-fertilization effect) D. Can take even if prior ectopic pregnancy, breast feeding, cardiovascular dz, migraines, liver disease or pregnant. E. All of Above

58 Questions?