Professional Documents
Culture Documents
Investigating Csa
Investigating Csa
Child Sexual
Abuse
Christine E. Barron, MD
Assistant Professor, Pediatrics
Warren Alpert Medical School
at Brown University
Objectives
National Data
Physical Examination
Red Flag Behaviors
Disclosures and Forensic
Interviewing
Multidisciplinary Team
Prevention
Risk Factors
Pedophiles
Can have normal peer sexual
relationships
Can be sexually oriented only to
children
Can be abuse reactive
Child-on-Child
Age
<=13
14
15
16
17
>=18
Mark Massi
14
15
16
17
>=18
Unable to consent
Child molestation
Third degree
Consensual
sex
Physical Examinations
American Academy of
Pediatrics
Physical Examination
Provides reassurance
Examine for treatable
conditions, STIs
Collect legal evidence
Chronic sequelae
Assists in the protection of the
child
Triage
Examination
General Physical
Examination
Abdominal Exam
Skin- appropriate UV light source
Bruising
Ligature/control marks
Oral
Sign of penetration
Sexually transmitted diseases
Physical Examination
Genitals
Colposcope
Tool for magnification and photodocumentation
Does not see what is not there
Estrogen Effect on
Hymen
Diagnosing Sexual
Abuse
Can the doctor tell?
Can any doctor complete
these evaluations?
Physicians
Not trained
Feel uncomfortable
Call normal findings abnormal
Call abnormal findings normal
Do Physicians Recognize
Sexual Abuse?
Physical Examination
Findings
Physical Exam
Physical Exam
Physical Exam
Examination
Techniques
Physical Findings
Physical Findings
Genital (Male)
Penile Abrasions
Bites, Bruises
Urethral/Anal Discharge
Sexually Transmitted Infections
Scars
Its normal to be
normal.
Joyce Adams, MD
Genital Anatomy in
Pregnant Adolescents:
Normal Does Not Mean
Nothing Happened;
36 pregnant adolescents seen for sexual
abuse evaluations
2/36 (6%) had definitive findings of
penetration (cleft to base of hymen)
4/36 (8%) had suggestive findings of
penetration (deep notches or clearly
visible scars)
Kellogg N et al Pediatrics 2004
Repetitive Penetration
Physical Exam
A
Physical Exam
Additional Exam
Findings
Stay Moral, Go
Oral
Adolescents do not consider
oral sex to be sexual activity.
Need to ask if anything has
been in the mouth!
Mimickers of Sexual
Abuse
Medical Conditions
Accidental Trauma
Vaginal Bleeding
Case
Physiologic Endometrial
Shedding
Prepubertal Vaginal
Bleeding
Endometrial Shedding
EndocrineHypothyroidism
Liver Cirrhosis
Coagulopathy
Precocious puberty
McCune-Albright Syndrome
Ovarian Cyst
Case # 2
Urethral Prolapse
Case
Lichen Sclerosus et
Atrophicus
Hypopigmented, well-circumscribed
areas of atrophic skin around genital
and/or anus.
Figure-of-eight
Subepithelial hemorrhages
Straddle Injuries
Case
Summary
Continued
Tumors
Urinary Tract
Urethral Prolapse
Hemorrhagic cystitis
Urate Crystals
Hematuria
UTI
Continued
GI Tract
Hematochezia
Anal Fissure
Dermatology
Forensic Evidence
Collection
et al Pediatrics 2000
(1)
(2)
(Alcohol)
Rohypnol- Flunitrazepam
Benzodiazepine
Sedation, loss of consciousness
Effects begin after 30 minutes
Peak within 2 hours
Persist up to 8-12 hours
Physical Examination
Sexually
Transmitted
Infections
Symptoms
Burning
Discharge
Itching
Bleeding
Anogenital Pain
Pubertal- may have no symptoms
Sexually Transmitted
Diseases
2973 Children evaluated for sexual
abuse:
1.7% Gonorrhea
1.3% Chlamydia
0.2% Syphilis
<1% Trichomonas
1.7% Condyloma acuminata (warts)
0.3% Herpes Simplex Virus
Who do we test?
Age of child
High risk of STI in assailant
(incarceration)
Household member with STI
Type of sexual abuse
Symptoms (vaginal discharge)
Acuity of abuse
Patient/family concern
High incidence in community
Multiple/unknown offenders
Gonorrhea*
Diagnostic
Syphilis* Diagnostic
HIV
Diagnostic
C trachomatis*
Diagnostic
T vaginalis
Highly suspicious
HPV
*Suspicious (Indeterminate)
Herpes simplex Virus (HSV)
*Suspicious
(Probable, Indeterminate)
Bacterial vaginosis
Inconclusive
Sexually Transmitted
Disease (STD)
Infections (STI)
Physical
Examination
In only a very small
percentage will it help to
make the diagnosis of child
sexual abuse by itself.
Corroboration:
Physical evidence
(FEK)
Behavioral
symptoms
Adult witnesses
and suspects
Medical evidence
(exam)
Other victims
Child witnesses
Child pornography
Computers
Cell Phones
Photos
Text Messages
Perpetrator confessions
Sexualized
Behaviors
Can the diagnosis of sexual
abuse be made based on
sexualized behaviors?
Behavioral Signs
Is that a red
flag being
waved?
Behaviors
Friedrich Normative
Sexual Behavior in Children
1991-- 880 Children ages 2-12
1998 -- 1114 Children ages 2-12
Administered specialized surveys
Excluded those with concerns sexual
abuse
Concerning Sexual
Behaviors
Influenced by:
Media (television, internet, videos,
magazines)
Decreased parental supervision
Decreased boundaries
Overt exposure
Sexually Abused
When to be concerned?
Interactive Session
Assessment component
Playing Doctor
Placing Objects in
Genital Orifices
Disclosures in
Sexual Abuse
The most important piece of the
puzzle
This may make your diagnosis
Disclosures in Sexual
Abuse
YES
Disclosure is a Process
BUT
Case
Case: Interview
Interviewing
Trained Interviewers
A Good Interview
Should
Assess competence
Address context initial disclosure
Avoid direct and leading questions
Document body language
Childs language
Remember children think concretely
Childs History
Build rapport
Use open-ended questions
Use childs language
Reassurance
Questions used in
Interviewing
your flower
Threats
Feels responsible, overwhelming guilt/shame
Denial
Disclosure
Tentative
Active
Recant
Reaffirm
Denial
Disclosure
Disclosure
Recant
Recantations
Reaffirm
Conclusion
WHY
Disclosures
Suggestibility
NO DISCLOSURES
Rarely show symptoms
By 18 months majority have only 10
words
Confirmed only with sexually
transmitted disease, semen, offender
confession, eye witness, abnormal
exam
Delayed Disclosures
Interview Stages
Introduction
Rapport-building/Developmental
Assessment/Narrative Practice
Ground rules
Substantive questions
Closure
Use of Media
Anatomical Dolls
Anatomical Drawings
Gingerbread Drawings:
Language Considerations
Interview
Interview
What next?
Interview
False Allegations
Phases of disclosure
I. Denial
Initial statement that he/she has not been
abused
Case example 9
4 year old female
Neighbor in adjacent apartment witnessed
patients adult male roommate sexually abusing
her
Witnessed filmed incident and called 911
Perpetrator confessed
Patient denied sexual abuse
Parental response to
disclosure
Parental Response
Parental Response
MDT
Strengthens the
investigative
process
Expertise from Law
Enforcement, Child
Protective Services,
Medical, Forensic
Interviews,
Prosecutors, and
others
Immediate response
Afterwards
MDT in Action
MDT in Action
PREVENTION
Negative:
PREVENTION
Parental Education
Truth versus myths
When to start- 10 yo is too late!
How often
Mental Health Care for parents prior abuse
Communication
Judgment
Caregivers
Myth Case
Prevention
Types:
Education
Home Visiting Programs
Adult Focus
ACE
Child Maltreatment
Physical
Sexual
Psychological
Parental
Etoh and Drug abuse
Domestic Violence
Incarceration
ACE
ACE
Heart disease
Liver disease
Depression
Substance abuse
Lung disease
Fetal death