Medical Evaluation of Child and Adolescent Sexual Abuse

Medical Evaluation of Suspected Child and Adolescent Sexual Abuse
Evidence-Based e-Learning and Clinical Reference
Nancy D. Kellogg, MD Joyce A. Adams, MD Jordan Greenbaum, MD

Professor of Pediatrics Clinical Professor of Pediatrics, Retired Director, Global Child Health and Well
University of Texas Health Science University of California, San Diego School Being Initiative
Center at San Antonio of Medicine
International Centre for Missing and
Consultant in Child Abuse Pediatrics Exploited Children
www.evidentialearning.com
Topic Preview © 2019 Evidentia Publishing. All Rights Reserved.
Child sexual abuse remains a major public health issue in the U.S. and around
the world. Healthcare professionals have a critical role in caring for abused
children. The medical assessment helps to:
• Determine the cause of physical findings.
• Evaluate and treat physical and mental health consequences of
abuse/assault.
• Gather forensic materials to assist in an investigation.
• Provide support, psychoeducation and referrals to child and family.
A solid knowledge base regarding trauma-informed care, the dynamics of child

sexual abuse, examination techniques and interpretation of findings, strategies
for forensic evidence collection and testing/treatment of STIs allows the care
provider to be of maximum assistance to vulnerable children and their
families.
© 2019 Evidentia Publishing. All Rights Reserved.
Inspired by Current Research
Nancy Kellogg, MD
Professor and Division Chief
UTHealth-San Antonio
Nancy Kellogg completed medical school and

pediatric residency at the University of Texas
Health-San Antonio. She evaluates children and
adolescents for suspected abuse or neglect at Center
for Miracles. She is medical director of the Forensic
Nurse Examiner program at Children’s Hospital of
San Antonio, and as Program Director, established
one of the first Child Abuse Pediatrics fellowships
following accreditation of the new subspecialty. She
served for 6 years on the American Academy of
Pediatrics Committee on Child Abuse and was
appointed as Medical Editor for the American Board
of Pediatrics Child Abuse Pediatrics sub-board. She
has presented numerous times on a variety of topics
to national and international audiences.
Joyce A. Adams, MD
Retired Clinical Professor of Pediatrics
University of California, San Diego School of Medicine
Dr. Adams has been involved in the medical evaluation of suspected sexual
abuse since 1984, first as the director of the Sexual Abuse Evaluation
Program at the University of Kansas Medical Center, and then at Valley
Medical Center in Fresno, California. From 1994 through 2014, she was
faculty in Pediatrics at the University of California, San Diego School of
Medicine. She also worked as a specialist in Child Abuse Pediatrics at Rady
Children’s Hospital, San Diego for 10 years. Dr. Adams currently provides
expert review of cases of suspected child sexual abuse for medical
providers at several locations inside and outside the United States.
Dr. Adams has published extensively in the field of medical evaluation of
suspected sexual abuse and is known for the development and continuing
revision of a medical literature-based tool for interpreting medical findings
in suspected sexual abuse. She speaks at national and international
meetings on topics of sexual abuse and adolescent gynecology, and is active
as an expert witness in child sexual abuse cases nationwide.
Dr. Adams has been active in several professional organizations for
physicians and is also an elected member of an honorary society for
physicians involved in the field of child maltreatment, the Ray E. Helfer
Society. Dr. Adams was among the first group of pediatricians to become
Board Certified in the newly recognized subspecialty of Child Abuse
EMAIL : jadams@ucsd.edu
Pediatrics.
Jordan Greenbaum, MD
Director, Global Child Health and Well Being Initiative
International Centre for Missing and Exploited Children
Clinical Assistant Professor, Dept of Pediatrics

Emory School of Medicine
Staff Physician
Stephanie V. Blank Center for Safe and Healthy Children
Children’s Healthcare of Atlanta
Jordan Greenbaum is a child abuse physician who received

her degree from Yale School of Medicine. She works with
victims of suspected physical/sexual abuse, neglect and sex
trafficking at the Stephanie Blank Center for Safe and
Healthy Children at Children’s Healthcare of Atlanta. In
addition, she is the director of the Global Health and
Wellbeing Initiative with the International Centre for
Missing and Exploited Children. Jordan provides trainings
on all aspects of child maltreatment for medical and
nonmedical professionals locally, nationally and
internationally. Her research interests focus on child sex
and labor trafficking and child sexual exploitation. EMAIL: virginia.greenbaum@choa.org
© 2019 Evidentia Publishing. All Rights Reserved. PHONE: 404-785-3829
Trauma-Informed Care,
Motivational
Interviewing, and Cultural
Considerations
Introduction
When interacting with abused and/or exploited children and their caregivers, it is
important to:
• Minimize any further trauma associated with the evaluation.

• Use an approach that facilitates trust and transparency.
• Emphasize patient/caregiver strengths and resilience.
This is best accomplished using a trauma-informed approach.
Five Interlocking Strategies
You can apply five interlocking strategies in providing trauma-informed care:
Give explanations
Protect safety
Build rapport. for what you want
and privacy.
to do.
Address issues of
Ask permission. confidentiality
and limits.
Keep these in mind when working with patients who may have experienced trauma.
Clinical Presentations Algorithm
Initial Presentation Clinical Presentations Algorithm
Child States Child Makes

Clearly They Child Makes
Were Abused
No Vague Or No Disclosure
Symptoms
/ Witness Or Unclear
Photographic Disclosure
Evidence
? ? ?
Yes Yes
Behavioral Anogenital Positive STI
Young Child With ? ? ?

Language Unknown Verbal Skills
Report, Refer For Investigation,
Skills
Yes Yes Yes
Complete Medical Assessment
? • Ask Verbal Assess For Mimics Of Ensure That
Children Screening Acute And Non-acute Appropriate Test
Interviewable
Questions. Anogenital Trauma Was Done And
Child
• Assess Sexual Confirmed (When
Clarify Disclosure Assess Verbal Skills Behaviors In Young Indicated), And
Before Attempting Children With That Results Were
To Clarify Disclosure Parent History. Interpreted
Correctly
Normative Sexual Behaviors: Ages 2-5
High prevalence/frequency behaviors (25-60%):
As high as 60%
• Touches genitals/anus at home (>in public).

• Touches mother’s breasts.
• Viewing/touching peer’s or new sibling’s genitals.
High Prevalence
• Standing/sitting too close.
• Trying to view peer/adult nudity.
• Displaying genitals to other children or adults.
• Behaviors are transient, occasional, and distractible.
References
Sexual Abuse And Sexual Behavior In Children
 Sexually abused children are 2-3 times more likely to display
sexual behaviors with greater frequency than children who
have not been sexually abused or who have psychiatric
diagnoses [REF1, REF2].
 About 28% of sexually abused children have sexual behavior
problems [REF3].
 Most common in younger children.
 Risk factors [REF1, REF2]:
 Onset of abuse at a young age (0-3 years).
 Father figure perpetrator.
 Abuse involving penetration.
 More than one perpetrator.
 Use of force.
 Self-blame.
Medical History
Medical History
Once a child or adolescent has disclosed abuse, the clinician should begin their
assessment with a medical history.
The history is often the most important consideration in the medical diagnosis of sexual
abuse. The clinician should have experience and knowledge in trauma-informed care,
and should focus on obtaining information important to ensuring that the patient’s
medical, mental health, and safety needs are assessed and addressed. When
conducted with respect and empathy, the medical assessment can allow the child to
share their feelings safely, and to begin their healing process.
Interview Approach: DO
Verify Statements.
Rephrase Questions.
Confirm Understanding.
Offer Options.
Be Supportive.
Be Neutral.
Use Safe Setting.
Physical Examination
Introduction
The physical examination should not be exclusively focused on finding trauma and
infections relating to sexual abuse or assault. This is a “head-to-toe” check-up as well,
and an opportunity to encourage the patient and the parent to voice any concerns they
have for the child’s health (“I have an itchy rash on my arms in the winter. Is this
normal?” “I get bumps sometimes when I shave. Why is that?”). The rapport and trust
gained from taking the medical history should be encouraged and continued during the
physical examination.
Although most examinations are normal, anogenital findings are sometimes missed due
to inadequate examination techniques, or patient anxiety which can limit visualization.
In addition, there are many anogenital findings (particularly in young children: see
“Clinical Presentations” section) that are misinterpreted as signs of acute or healed
trauma. Gaining clinical expertise, using photo-documentation, and keeping up with
new knowledge in the field is recommended, and has been found to enhance accuracy
in the interpretation of examination findings.
Examination Positions
Examination Positions and Techniques
Positions Techniques
• Prone knee-chest. • Labial separation.
• Supine knee-chest. • Labial traction.
• Supine frog-leg. • Gluteal lifting (in prone knee-chest)
• Supine lithotomy. • Sequential gluteal lifting (in prone knee-chest)
• Lateral decubitus. • Tracing the hymenal rim with a small cotton-
tipped applicator
• Tracing the hymenal rim with a large cotton-
tipped applicator
• Tracing the hymenal rim with a Foley catheter
• Floating the hymen with water
Choosing Examination Positions and Techniques
Use the following tables as a guide to examination positions, as well as examination and confirmatory techniques.
The positions are visualized on the following pages.
Prepubertal Child Genital Examination Anal Examination

Examination Positions Supine Frogleg or Lithotomy Supine Knee-chest
Prone Knee-chest (PKC) PKC
Lateral Decubitus
Examination technique Labial separation and traction Buttock separation
PKC with gluteal lift PKC with gluteal lift
Speculum examinations not indicated
unless child sedated
Confirmatory technique Floating hymen with water or saline Reassess after bowel movement,
PKC with gluteal lift ambulating, or alternate position
Pubertal Child Genital Examination Anal Examination

Examination Positions Supine lithotomy Supine knee-chest
PKC with gluteal lift PKC
Lateral decubitus
Examination technique Labial separation and traction Lateral buttock separation
Speculum examination can be done if Gluteal lift in PKC
Tanner 3 or greater
Confirmatory technique Trace hymenal rim with cotton tip swab Reassess after bowel movement,
Foley catheter ambulating, or alternate position
PKC with gluteal lift
Genital Examination Positions
Extensive visualization of examination positions and

techniques.
Supine Frogleg or Lithotomy Prone Knee-chest (PKC)
Septate Hymen
A septate hymen is a normal anatomical variant that is usually noted in prepubertal

children, but is sometimes seen in adolescents, even those with a history of genital-
genital contact. The septum may separate traumatically or atraumatically.
Images with rollovers and annotations to highlight normal

anatomy, congenital and developmental variations, as well as
acute and non-acute trauma findings.
Mimics Of Trauma And Findings
Misattributed To Trauma Or
Abuse
Examples of Findings Caused by Other Medical Conditions
• Erythema
Includes images and self-
• Increased vascularity
• Labial adhesions assessments.
• Friability of the posterior fourchette
• Vaginal discharge not caused by sexually transmitted infections
• Anal fissures
• Venous congestion or pooling in the perianal area
• Anal dilation in a child with pre-disposing conditions
• Urethral prolapse
• Lichen sclerosus
• Vulvar ulcers
• Rectal prolapse
• Post-mortem lividity of genital or anal tissues
Accidental Or Abusive Trauma
Findings Caused by Trauma
•
•
Acute trauma to genital/anal tissues.
Includes images and self-
Acute lacerations or bruising of labia, penis, scrotum, or perineum.
• Acute laceration of the posterior fourchette or vestibule, not involvingassessments.
the hymen.
• Bruising, petechiae, or abrasions on the hymen.
• Acute laceration of the hymen, of any depth; partial or complete.
• Vaginal laceration.
• Perianal laceration with exposure of tissues below the dermis.
• Residual (healing) injuries to genital/anal tissues.
• Perianal scar (a very rare finding that is difficult to diagnose unless an acute injury was previously
documented at the same location).
• Scar of posterior fourchette or fossa (a very rare finding that is difficult to diagnose unless an acute injury
was previously documented at the same location).
• Healed hymenal transection/complete hymen cleft-a defect in the hymen below the 3-9 o’clock locations
that extends to or through the base of the hymen, with no hymenal tissue discernible at that location.
• Signs of FGM or cutting, such as loss of part or all of the prepuce (clitoral hood), clitoris, labia minora or
labia majora, or vertical linear scar adjacent to the clitoris.
Forensic Evidence
Overview of Forensic Evidence Collection
Forensic evidence collection is generally done when a victim presents within 72-96
hours of a sexual assault. However, facilities and regions vary in protocols, including
time interval cutoffs for the collection of evidence.
Forensic evidence includes semen, sperm, blood, saliva, and trace evidence such as hair,
fibers, lubricants, and epithelial cells. Although not included in the forensic kit,
toxicology/drug screens should also be considered whenever patients report a loss of
memory or a change in mental status, or the examination suggests possible use of drugs
or alcohol.
Most areas of the U.S. have designated facilities for forensic evidence collection
procedures, and when possible, the victim should be referred to these facilities
immediately.
Physical Examination: General Procedures
• Have the patient remove his/her clothing while standing on the white sheet provided in the
kit. Afterwards, fold this paper and include it in the kit for processing (may contain fallen
debris from clothing). If the child is unconscious, carefully cut the clothing. Do not cut
through any noted stains/secretions. A balanced approach brings
• research
Clothing should be dried and bagged for evidence (paper into practice.
bags, not plastic).
• If the victim scratched assailant, collect fingernail debris.
• Comb the head and pubic hair onto paper and submit for analysis. If it is determined later
that a patient standard is needed, hair can be plucked at that time.
• Photograph and document injuries; use color standard and size reference.
• Body swabs; utilize alternative light source when available to identify sampling sites.
• Blood samples for genetic markers.
Sexually Transmitted Infections
Introduction
The identification of sexually transmitted infections (STIs) in suspected victims of
sexual abuse has presented clinical and diagnostic challenges. Each STI may present
with varying or no clinical features, and the incubation period may extend up to 4 years,
in the case of human papillomavirus. Once a clinician has decided to test for an STI,
there are a number of diagnostic tests available, each with varying sensitivity and
specificity rates as well as sample site-specific restrictions.
Even when an STI is confirmed in a child, the determination that the infection was
sexually transmitted can be problematic. Clinicians must be knowledgeable about the
indications for STI testing, the appropriate tests to utilize, and the possible modes of
transmission in order to accurately detect, interpret and treat an STI in a child or
adolescent.
An STI Decision Tree: An Initial Clinical Approach
Type of
finding
Ulcer or Exophytic
Discharge
vesicle lesion
Routine Test for

Culture for Common
bacterial Test for HSV bacterial Condyloma Molluscum
STI wart
culture infection
Additional topics in STIs:
Clinical Presentations of Specific Sexually

Transmitted Infections
Overview of Sexually Transmitted

Infection Testing Modalities
Treatment, Prophylaxis and Follow-up

Care
STI Testing Intervals: U.S. CDC Guidelines
STI Incubation Initial 2 weeks 4 weeks 12 weeks
Gonorrhea 10-14 days X X
Chlamydia 10-14 days X X
Trichomonas 10-14 days X X
Syphilis 6-8 weeks X X X
Hepatitis B/C 6-8 weeks X X X
Herpes Simplex 3-14 days X X
Virus
HIV 2 weeks to 4 X X X
months
May test at 6-8 weeks, and 4 months
from contact.
HPV/anogenital 2 weeks to ? X X X
warts* years.
Suggested Testing Intervals for STI's

• *Anogenital warts is usually diagnosed clinically (visualizing the lesions during direct inspection); in rare cases, small lesions may be visible within 2 weeks
after assault. Follow up examination after an acute assault may be important to detect this infection (in unimmunized individuals).
• Testing intervals are based on typical incubation periods and assuming the initial examination is done within 5 days of sexual assault/abuse.
• If sexual abuse is chronic, initial testing alone may suffice.
• Testing should be based on patient history, examination findings, patient/parent wishes, symptoms, and known www.evidentialearning.com
perpetrator risk factors.
Interpretation of Medical
Findings in Suspected
Child Sexual Abuse
Annotated images for each

finding supports confidence in
interpreting findings.

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Medical Evaluation of Suspected Child and Adolescent Sexual Abuse

Evidence-Based e-Learning and Clinical Reference

Nancy D. Kellogg, MD Joyce A. Adams, MD Jordan Greenbaum, MD

A solid knowledge base regarding trauma-informed care, the dynamics of child

Nancy Kellogg completed medical school and

Clinical Assistant Professor, Dept of Pediatrics

Jordan Greenbaum is a child abuse physician who received

• Minimize any further trauma associated with the evaluation.

This is best accomplished using a trauma-informed approach.

Child States Child Makes

Young Child With ? ? ?

• Touches genitals/anus at home (>in public).

Prepubertal Child Genital Examination Anal Examination

Pubertal Child Genital Examination Anal Examination

Extensive visualization of examination positions and

Supine Frogleg or Lithotomy Prone Knee-chest (PKC)

A septate hymen is a normal anatomical variant that is usually noted in prepubertal

Images with rollovers and annotations to highlight normal

• If the victim scratched assailant, collect fingernail debris.

• Blood samples for genetic markers.

Routine Test for

Clinical Presentations of Specific Sexually

Overview of Sexually Transmitted

Treatment, Prophylaxis and Follow-up

Suggested Testing Intervals for STI's

Annotated images for each

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