3. A ruler, preferably one approved by the American Board of Forensic Odontologists (ABFO) (Fig. 21–1). These display a circle upon their surface, to allow for adequate assessment of picture distortion as a result of the angle at which the picture was taken. Alternatively, you can use a measuring tape.

4. A color chart (Fig. 21–2) to allow for assessment of the color quality of the image. (See the color version on Student Consult).

5. A detailed body map showing anterior, posterior, medial, and lateral surfaces of all areas of the body (Fig. 21–3 and a full-page version on Student Consult).

FIGURE 21–1 ABFO ruler.

FIGURE 21–2 Color chart (a color version of this figure can be seen on Student Consult).

FIGURE 21–3 A sample body map.

(Modified from http://www.pain-initiative.com/e1833/e5688/e5887/diagram_eng.gif)

Careful documentation of the findings on a body map is required. A body map, accompanied by a careful written description and photographs, is the most efficient and accurate way to document injury shapes and locations and is much more convenient to use. Include notes on the color, size, and shape of the lesions and their overall appearance and pattern.

Obtaining Pertinent History

The Student Consult Web site offers an important section on the triage of referrals, the need for a physical examination, and issues to consider in the scheduling of an assessment.

Formulating questions for history of present illness

For several reasons, many families do not use proper terminology for genitalia with their children. This can lead to misunderstandings. Therefore, you must find out whether the child uses special terms to describe their genitalia (e.g., “bird,” “flower,” “wiener”). You can ask a parent or caregiver at an appropriate time in the history process. If however, the child is not accompanied by someone who would know such details, you can ask the child. Never assume a child knows the proper terminology to describe their genitalia and, similarly, do not assume that you know what the child means when he or she makes a statement such as “He touched my noonoo.” Whereas going along with a child or parent’s euphemism for genitalia may be reasonable in a routine office visit, it is not acceptable when child abuse is suspected. There must be no confusion about what is being discussed. If you encounter a vague euphemism, ask the child to clarify it. Your conversation can be as follows:

Child:	“He hurt my noonoo.”
Physician:	“Hmmm, I’m not sure I know exactly what you mean when you say noonoo, do you know another word for it?”
Child:	“You know, my privates!”
Physician:	“Oh, I see. Just to be sure I’m thinking of the right privates, “Can you show me where your noonoo is?”
Child:	“There, silly!”

If a child protection agency has already interviewed the child, you should be able to obtain a relevant history to guide the physical examination from the child protection worker or the child’s parent or caregiver. When this is not possible, be very careful about how you ask questions to a child, so as not to be perceived to have led the child to disclose what he or she said. Take scrupulous notes. The following conversation illustrates an inappropriate questioning technique. The doctor is leading the child to make statements that might otherwise not have been made:

Child:	“He put his stick in my bird.”
Physician:	“Do you mean his penis?”
Child:	“Yes.”
Physician:	“Is your bird your vagina?”
Child:	“Uh-huh”
Physician:	“Did it hurt?”
Child:	“Yeah.”
Physician:	“Did he put it in your mouth?”
Child:	“Yes.”
Physician:	“How about your bum?”

A better way is simply to indicate your willingness to hear more. Do your best not to look or sound shocked or distressed; it may discourage the child from telling you more. Just be interested in what the child has to say. A child who is ready and willing to disclose will give you information without your needing to ask many questions. The following example illustrates a better way to encourage the child to talk more:

Child:	“He put his stick in my mouth.”
Physician:	“In your mouth?”
Child:	“Yeah and sometimes my bird too.”
Physician:	“Hmmm. What’s that like?”
Child:	“Kinda funny ’cause it gets all big and it stands up.”
Physician:	“And how does that feel when that happens?”
Child:	“Goodish badish.”
Physician:	“Really… anything else?”
Child:	“Kinda wet and goopy too.”
Physician:	“I see…”
Child:	“But that’s okay—we use Kleenex on the night table to clean up.”

Though the child’s disclosure is not clear (we don’t know what the stick or the bird are), you have enough information to suspect inappropriate sexual contact with ejaculation. Without having led the child, there is now enough reason to consider testing for STIs and to look for sequelae of penetrating genital trauma. If you have not already done so, or if you have not succeeded in doing so, clarification of the terms stick and bird will be done by child welfare workers when they interview the child.

Remember, young children often use terminology to which they can relate to describe acts that are developmentally beyond their understanding and for which they lack the proper terminology. A 6-year-old child who discloses that his cousin “peed in (his) mouth” may in fact be describing ejaculation. At this age, peeing may be the only function a boy knows for a penis. Not knowing how to describe semen, the child may use the word pee because it represents the only experiential knowledge he possesses for a liquid substance coming from a penis. It is important to realize that the child is not lying about what happened but rather is explaining it, in his own words. Your knowledge of child development can be most important in explaining this concept to investigators who may have no experience with young children or knowledge of child development.

Past medical history

To fully assess all possibilities, review any history of genital trauma (such as straddle injuries or past surgeries) that may have caused injuries or left scars, which you may identify during the examination. As well, find out about the patient’s pubertal development, noting age at thelarche and menarche, date of the last menstrual period, past sexual activity (whether or not it was consensual), use of birth control methods and contraception, and the type of feminine hygiene products used (pads versus tampons), as appropriate.

Functional inquiry

As with all other conditions, a differential diagnosis must be considered. Anal fissures and perianal pain or bleeding may be secondary to constipation. Similarly, vulvovaginitis can lead to vulvar redness, pain, discharge, and odor. Pinworms may cause itching and discomfort. All of these symptoms could be misconstrued as symptoms of sexual abuse, and you can play a vital role in identifying a condition that mimics abuse.

Family and social history

Take a moment to find out about prior abuse in the family. Ask about domestic violence and determine how supportive the family environment is. Ask specifically whether the parent(s) have their own history of sexual abuse and how they have dealt with it. This information will be extremely informative and may well predict the ability of the child’s caregivers to be supportive and protective in the future. A parent who has not dealt with or denies his or her own abuse may not be able to support the child’s healing or will likely need significant counseling services to do so. Such information will be critical with child welfare workers and will help them make placement decisions.

Physical Examination

Many children referred for evaluation of possible abuse are, understandably, reluctant to be examined. This is particularly true in the case of older female sexual abuse victims who may be asked to undergo an examination by a male physician.

A child’s refusal to be examined may not please some parents who may be very assertive and may demand that the child be examined against her wishes. Faced with such a situation, remember that your primary responsibility is to maintain the patient’s well-being. As long as there is no medical urgency, if a child is reluctant to be examined, it is better to delay the examination or cancel it altogether rather than force a child to be examined against his or her will. Genital examinations under anesthesia should be done for undiagnosed ongoing bleeding or for foreign body removal only. It is unacceptable to perform such an invasive procedure simply to assess the external genitalia in the absence of a serious disease or symptoms.

Give praise and congratulations to the child for having had the courage to say “No” to the examination, to speak up for oneself and protect his or her privacy. Such an approach not only respects the young patient’s autonomy but also reinforces the development of good boundaries while helping the child build positive self-esteem and self-worth.

Key Point

Giving victimized children a sense of mastery over their bodies and choices is an important way to avoid revictimizing a child who has been abused and to give them back some of the control they lost as part of the abuse.

Whether for acute or historical sexual abuse, it can be difficult to conduct an examination by yourself. If possible, have someone assist you. You will find this most helpful for positioning, labial traction, collection of swabs, and photography. For cases of possible sexual abuse, you should have additional materials on hand, including:

1. A bottle of warm sterile water, preferably with a dropper, to drop some water on the hymen. Alternatively, a small syringe can also control the flow adequately.

2. A Foley catheter may be helpful for examining postpubertal girls, to permit better visualization of the hymen.

3. Various swabs for the collection of specimens for chlamydia, gonorrhea, or trichomonas, as well as for wet mount, as indicated by the history. The number and types of swabs required will vary with individual laboratory capabilities and testing methods.

4. A speculum may be necessary in selected cases of abuse, but for post pubertal and sexually experienced girls only.

5. A colposcope, handheld magnifying glass, or video camera, if available, to magnify the examined areas.

Key Point

If you are confident that a hymen is normal, you can reassure the parents, and this may help calm their fears. Be careful, however, not to comment about the significance of hymenal abnormalities or variations, if you are not familiar with the current literature on child sexual abuse. If you have any doubt about the appearance of the hymen and its significance, refer the child to a child abuse pediatrician or pediatric gynecologist, preferably one with experience in child abuse.

Examination for Sexual Abuse

The Student Consult Web site offers a section on understanding fundamental anogenital anatomy in children, a concept that must be firmly grasped before you attempt any physical examination. It includes many additional pictures pertaining to the different configurations a normal hymen can have, to help you understand its importance in the context of an examination for sexual abuse. Physical examination for possible evidence of sexual abuse should include all areas of the body. Performing the genital examination should be done last and as part of a complete physical examination only. This allows the child time to become comfortable with the examiner and diverts the focus from the genitalia as the only area of interest.

In addition to yourself and the patient, it is prudent to have a second examiner or other health care professional present when you perform the genital examination. If no other healthcare professional is available, a person of the child’s choosing may be appropriate. This will help ensure that none of your actions are misinterpreted as inappropriate sexual touching. While the protocol of having a chaperone present protects you medicolegally, recognize the sensitive nature of examining the genitals of a child who may have been sexually abused. Besides, this third person may be a great source of support for the child during the examination.

In girls, the examination for possible sexual abuse is limited to the assessment of the external genital structures only. It is not the same as a gynecologic examination, which is an internal examination. For information on performing a gynecologic examination, see Chapter 18.

In cases of historical sexual abuse, the physical examination will most likely be normal. With more recent contact, however, obvious or subtle injuries may be found. Look for and document the presence of abrasions, irritation, ecchymoses, lacerations, edema, or scarring. Only in cases of brisk or undiagnosed vaginal bleeding should you need to perform an internal, speculum exam on a prepubertal or sexually inexperienced girl. Most often, this will require an examination under anesthesia, and you should enlist the help of a gynecologist or general surgeon.

Key Point

Unless there is undiagnosed bleeding, a speculum exam is not warranted in prepubertal or sexually inexperienced girls.

The supine frog-leg position (Fig. 21–4) is an ideal initial position to visualize the external structures of the vulva and provide an initial view of the hymen. This position should be used for visualization of the female genitalia during well-child visits, when a more in-depth look at the hymen is not required. This position has the advantage of being less invasive and more natural, helping the patient relax. It can be used on an examination table or, for the insecure younger patient, on a parent’s lap. In this position, the labia majora usually separate automatically, exposing the introitus. Gentle lateral traction of the labia majora can help visualize the labia minora, clitoris, posterior fourchette, and hymen.

FIGURE 21–4 Supine frog-leg position.

(From McCann JJ, Kerns DL: The Anatomy of Child and Adolescent Sexual Abuse: A CD-ROM Atlas/Reference, Intercorp Inc., 1999)

Key Point

Be very careful not to exert too much lateral traction on the labia. The posterior fourchette is very fragile and can easily be split by too much lateral traction.

Step 2: Frog-leg position with downward traction of the labia majora

Downward labial traction allows for better assessment of the hymen and vestibule while minimizing the risk of tearing the posterior fourchette. Grasp the labia majora bilaterally between your thumb and forefinger, and gently pull both labia toward you in a downward and slightly outward direction. As long as both labia are pulled in tandem and in the same direction, there is little risk of discomfort or injury. This maneuver creates a tunnel which elongates the vestibule and stretches the hymen, allowing its edges to separate. Inferior labial traction is often all that is necessary to separate adherent hymenal edges. The perspective of the tunnel created by traction can be changed by pulling the labia in tandem anteriorly, laterally, or posteriorly.

Figure 21–5 illustrates the labial traction and retraction techniques and the difference in hymenal visualization that they offer.

FIGURE 21–5 A, Lateral labial traction. B, Downward labial traction alters the soft tissue anatomy to offer a different view of the hymen.

(Adapted from McCann JJ, Kerns DL: The Anatomy of Child and Adolescent Sexual Abuse: A CD-ROM Atlas/Reference, Intercorp Inc., 1999)

If the labial traction technique does not allow the edges of the hymen to separate easily, apply a few drops of warm water to the hymen with a dropper or syringe. This should not be painful. The resulting accumulation of water on the hymen will serve to float its edges, allowing you to see them more clearly.

Step 3: Prone knee-chest position

Once the hymen and other genital structures have been identified and examined, if any abnormality is suspected, you must examine them again with the child in the prone knee-chest position (Fig. 21–6). This is especially important when suspicious findings are identified with the child in the supine frog-leg position. The hymen may look abnormal in the supine position because of the effects of gravity on the anterior vaginal wall and to the adherence of mucosal surfaces. By turning the patient into the prone knee-chest position, the effects of gravity are reversed by pulling the posterior hymenal edge and anterior vaginal wall in the opposite direction. If they are real, the same defect(s) seen in the supine position should be visible with the child in the prone knee-chest position. Findings that disappear indicate positional changes in the hymen’s appearance and are not true abnormalities.

FIGURE 21–6 The knee-chest position.

(From McCann JJ, Kerns DL: The Anatomy of Child and Adolescent Sexual Abuse: A CD-ROM Atlas/Reference, Intercorp Inc., 1999)

To visualize the hymen with the child in this position, place your thumbs lateral to the area of the posterior fourchette, with the palms of your hands on the patient’s buttocks. With your thumbs, gently lift the tissues superiorly and laterally, in effect, lifting the posterior vaginal wall against gravity (Fig. 21–7). Using this technique, the posterior hymen should be clearly visible, smoothed out by the effects of gravity. Figure 21–8 demonstrates the striking conformational change in the hymen when the patient is changed from the supine frog-leg position to the prone knee-chest position.

FIGURE 21–7 Examination of the hymen in the knee-chest position.

(From McCann JJ, Kerns DL: The Anatomy of Child and Adolescent Sexual Abuse: A CD-ROM Atlas/Reference, Intercorp Inc., 1999)

FIGURE 21–8 Difference in the appearance of the hymen in the same patient, using the (A) supine frog-leg position and (B) knee-chest position.

(Adapted from McCann JJ, Kerns DL: The Anatomy of Child and Adolescent Sexual Abuse: A CD-ROM Atlas/Reference, Intercorp Inc., 1999)

The prone knee-chest position also offers an ideal opportunity to visualize the anus. The lateral knee-chest position is also suitable for adequately exposing the anus, although it requires more manipulation of the buttocks by the examiner.

Key Point

Remember that changing the patient from the supine frog-leg position to the prone knee-chest position turns the patient 180°. As a result, any defect seen in supine should be seen directly opposite its original position in prone knee-chest. For example, a defect seen at the 7 o’clock in supine position will be seen at 1 o’clock in prone knee-chest position.

Specialized techniques for examining the postpubertal patient

The thick redundant hymen, typical of postpubertal females, is much more difficult to assess adequately. Though labial traction may help, it is usually insufficient. Using a moistened swab and a Foley catheter are two techniques that may be useful to allow clearer visualization of the posterior rim of the hymen. Another method, the blue balloon technique, can be used to increase contrast between tissue edges.

Key Point

The prepubertal hymen is extremely sensitive. Never use a swab or other instrument to try to separate its edges or otherwise explore it. This will cause pain and end any fruitful attempt at a physical examination.

1. Swab technique

Insert a pre-moistened swab into the introitus (although the hymenal opening is often difficult to see, aiming the swab in the center of the hymen is generally successful). While retracting the labia majora and minora with the fingers of one hand, use the other hand to gently run the swab along the posterior rim of the hymen, inspecting its continuity as you proceed. Alternatively, have an assistant perform the labial traction while you manipulate the swab.

If the swab slips out into the vestibule, be sure to determine whether it has slipped out because of the presence of a hymenal transection or because of the examination technique (Fig. 21–9). Normally, the posterior hymen should not exhibit deep transections that extend to the vaginal wall.

FIGURE 21–9 Use of a swab to examine the continuity of the posterior hymen. Note the hymenal cleft identified by the swab and the presence of a Foley catheter to stretch the hymen.

(From McCann JJ, Kerns DL: The Anatomy of Child and Adolescent Sexual Abuse: A CD-ROM Atlas/Reference, Intercorp Inc., 1999)

Key Point

The swab used in this technique should not be sent for culture. In postpubertal patients, the detection of chlamydia and gonorrhea requires endocervical samples.

2. Foley catheter technique

If the less invasive swab technique is not successful, you can insert the tip of a Foley catheter into the introitus, inflate the balloon, and gently pull the catheter out of the vagina. Doing so will stretch out the margins of the hymen and allow for visualization of the posterior rim (Fig. 21–10).

3. Blue balloon technique

FIGURE 21–10 Use of a Foley catheter to stretch the hymenal edges, identifying a hymenal septum.

(From McCann JJ, Kerns DL: The Anatomy of Child and Adolescent Sexual Abuse: A CD-ROM Atlas/Reference, Intercorp Inc., 1999)

If the hymenal edges are difficult to appreciate, a standard deflated blue balloon can be inserted over the tip of the swab to increase the contrast between the pink mucosal edges and provide a sharper image of the hymenal edges. Alternatively, instead of a balloon, you can use one of the fingers of a purple or blue examination glove.

Speculum Exams

Speculum exams are rarely indicated in evaluating possible sexual abuse. Use of a speculum is contraindicated in patients with no prior sexual experience, in acute sexual abuse with obvious trauma, or in prepubertal patients. A speculum is only necessary to allow for visualization of the cervix and for collection of endocervical swabs. If you plan to use a speculum, visualize the hymen in its entirety prior to proceeding to the speculum exam. This will avoid documenting possible iatrogenic trauma as preexistent.

Perianal Examination

Assess the perianal area for signs of trauma or STI. Scars, fissures, herpetic lesions, or papillomas may be visible. It is not necessary to perform a digital rectal examination, unless indicated by signs and symptoms. Document the presence of fissures, scars, bruising, or swelling.

Be careful not to confuse perianal venous stasis for bruising. Allow the child to move around and stand for a moment and re-inspect the perianal area. Venous stasis usually disappears with changes in position.

The Student Consult Web site offers a section on STIs and the indications to test for their presence in cases of suspected sexual abuse.

Documentation in sexual abuse cases

Be careful how you interpret genital examination findings. If you document a normal genital examination, you can reassure the patient and child welfare authorities that everything appears normal. Many people still do not understand that a normal physical examination does not mean nothing happened. Therefore, accompany your reassurance with a statement that the presence of a normal physical examination neither refutes nor supports a disclosure of sexual abuse. Be sure to point out that the medical history and disclosures are more important than the physical examination in establishing whether abuse occurred.

If you feel that the physical examination was abnormal, it is safest and best to refer the patient to a colleague with more experience in child sexual abuse for further assessment. Do not imply with certainty that a finding represents trauma from sexual abuse. It is better to state that there is a finding that warrants further evaluation. Most tertiary pediatric centers have child maltreatment experts who can provide a valuable second opinion.

Case Histories

Case History 1

History. Mrs. MacLeod arrives in your office, very upset. She booked one of your “urgent” spots at the end of the day on a Friday afternoon. When you enter the room, she gets to her feet and starts telling you how grateful she is that you could see her and her daughter, 6-year-old Chelsea, so fast. In the same breath, she starts telling you that Chelsea just told her that her father, whose house she returned from that morning, had touched her bird and that it hurt. She goes on to say “I knew it, I just knew that that man couldn’t be trusted; you know we separated because of his porn addiction. I need you to examine her; I just know the creep’s done something—whatever it takes, an internal exam, whatever, just do it; I want him out of her life, now!” Meanwhile, Chelsea looks at you from the corner of her eyes, quiet and anxious-looking.

Strategies

In this situation, the concern is obviously about sexual abuse. However, there are many lacking details, details that would help you decide how to go about your assessment. Chelsea’s mother is, however, not in any position to think about things clearly at this time. She needs to be calmed and to be provided with guidance. Although she loves her daughter and wants to protect her, Mrs. MacLeod is tangled up in her emotions, which may hinder her ability to be rational in her approach. On the other hand, Chelsea, a very young child, does not have any control over the situation and is at the mercy of her mother’s reactions. It is your job, as her pediatrician, to ensure that she feels safe and comfortable and to assess whether or not she requires a physical examination and is in need of protection from her father.

Your approach should be to interrupt Chelsea’s mother’s unfiltered disclosure of information and to redirect her attention to Chelsea’s needs. Suggest taking a moment to find a quiet place for Chelsea to play while you talk to Mrs. MacLeod alone. This should suffice to stop Chelsea’s mother from making inappropriate comments about Chelsea’s father in the child’s presence.

Because Chelsea’s mother is overwhelmed with the new information she has to deal with, take the lead in asking questions about the alleged event and surrounding circumstances. This will ensure that you set the tone and agenda for your discussion and will allow you to get the information you need.

Explain your train of thought to Chelsea’s mother. Explain that there is a medical element that you can address and there is a child protection element, which you can help facilitate, and that you need to understand the sequence of events and the details of Chelsea’s disclosure to help you decide on the best course of action. Explain your duty to report and the limits of confidentiality. Finally, give details as to how you will go about deciding whether or not Chelsea needs to be examined.

Taking the time to make things clear and explain the overall process will help Mrs. MacLeod relax and trust you, thus allowing you to go about your history-taking, uninterrupted. As soon as it is appropriate in the history, bring Chelsea back into your examination room. This will allow her to familiarize herself with the environment, stay close to her mother for support, and interact with you before any attempt at physical examination, if that is warranted.

Once you have gathered all of the necessary information, decide on whether or not you feel that Chelsea needs protection from her father. If you do not feel there is any concern, facilitate Mrs. MacLeod’s reporting of her concerns to a child welfare authority. If, however, you share her concerns or if you are uncertain about the whole situation, report it yourself. In either case, make a plan for follow-up, outline how Mrs. MacLeod can be supportive to Chelsea, encourage her to seek counseling or support for herself, and reassess the situation at a later date.

Assessing Children for Physical Abuse and Neglect

Triage of referrals

The Student Consult Web site offers a section on triaging cases of physical abuse.

Formulating questions

As with sexual abuse, keep the questions as open-ended as possible. Of course, not all open-ended questions will lead to clear answers. Do not feel that it is your responsibility to extract a clear disclosure about the nature of the child’s injuries. Your role is to document injuries, obtain a medical history, determine whether a medical condition might explain the findings, and interpret the findings.

To increase the likelihood that a caregiver will be cooperative and informative during history taking, avoid accusatory tones. If an injury that is almost certainly abusive is found, stating, “Billy is seriously injured; tell me about it” is far better than “Who did this to Billy?” or “What happened here?”

Even with children, good open-ended questions will help you obtain better information. When asking about injuries, start with a very broad statement expressing interest without sounding like an investigator. For example:

Physician:	“What’s this?”
Child:	“A bruise.”
Physician:	“How did you get it?”
Child:	“It’s from the slipper.”
Physician:	“What do you mean?”
Child:	“You know, when I pee in my bed.”