The Role of the Non-Sexual Abuse Specialist
Community Health Care Professional

It cannot be assumed that all Child Sexual Abuse (CSA) cases start with a call to the DFACS office which then instructs the family on how to proceed next. Many concerned family members start the investigative process by taking the child to their community health care provider first, either as a response to the child's medical problem, or their own wish to investigate an allegation.

It is an equally unrealistic expectation that all child & family health care professionals are going to have extensive specialized training in the assessment of possible CSA cases.

Therefore, the current section addresses the question of what a non-sexual abuse health care specialist should do at this very first contact, and conversely, what he/she should not do.

Above All, Do No Harm

Abstract: A community healthcare provider who is untrained as a sexual assault examiner should refer any and all suspected cases of abuse to the nearest center where forensically educated staff can provide exams. In most cases, sexual abuse does not manifest itself with physical evidence. Exams need to maximize any evidence and preserve it in a forensically defensible manner.

As medical professionals who work with children, most nurses' heartfelt desire to help the child and the parent can often overshadow their education and training. When a parent presents to the primary care setting, the health department, or to a nurse neighbor with the startling news that the child has possibly been sexually abused, the response which often rises to the top and frequently overrules the basic knowledge-based response is one generated by emotion. The parent wants you to check the child to see if "anything is wrong" and determine whether they should "bother" with the travel and expense of going to an emergency room or specialist's office for a "more complete" examination.

As the provider for most of this child's wellness checks through the years, it is very difficult to say "I can't do that for you" to that devastated parent. Yet reason needs to rule for the health care provider to be guided by the words that physicians repeat as part of their Hippocratic Oath: "above all, do no harm."

Physical Findings in Sexual Abuse

It is a frequently recorded fact that 80 % of children who are victims of a known sexual assault (admitted by the offender) have a normal physical exam (Adams et.al., 1994, Krugman, 1998). This can occur for any of the following reasons:

• There could have been a delay in reporting the incident(s) by the child out of fear or intimidation.
• Small injuries heal rapidly with new epithelial tissue generating in 4 to 7 days.
• Offenders usually do not use enough force to cause tissue trauma.
• The nature of abuse is such that the perpetrator seeks to gain the child's silence and cooperation so that participation is guaranteed over time.
• Behaviors deemed sexually abusive to children extend along a continuum from no touching, to touching, to exploitative behaviors (Robinson & McKenzie, 2000).

Several investigators in the late 1980's made attempts to define characteristics of genitalia of males and females that would be "diagnostic" of abuse. Cantwell (1983), and the team of White, Ingram, & Lyna (1989), described vaginal openings greater than 4 cm as a diagnostic criteria. Hymenal tears and tissue bands inside the vagina were the pathognomonic identifiers in the study by Emans et al. in 1987. Hobbs and Wynne (1989) used the findings of rectal reflex and dilation as their primary focus. In the same year, Hanson and others thought that the definitive diagnostic characteristic was condylomata.

The 1990's brought a series of studies to refute the investigators of the previous years. Surprisingly, little information was actually known about the normal range of genital characteristics in children. What was to be discovered in these newer studies would cast serious doubts on the diagnostic "validity" of those previous genital benchmarks.

McCann et al. (1990), and Berenson, Somma-Garcia, and Barnett (1993) found that by using a control group of pre-pubertal children who had been carefully screened to rule out abuse they were able to identify many hymenal tears, and tissue bands, as well as reflex and anal dilation in the normal population.

The only physical evidence of a definitive sexual assault is the presence of sperm in a pre-pubertal girl (Aiken, 1990). What must be remembered is that even this has a disclaimer. Gardner (1993) reminds us that sperm may be present as the result of consensual intercourse. These studies help show that the diagnosis of child sexual abuse is difficult and the proof of child sexual abuse should not rest on the physical examination alone.

Immediate Actions to Take

Although the non-specialist health care provider should refuse to examine the child for forensic purposes, this does not mean that she/he can not be helpful to them. He/she can and should:

• Assure that the child is safe, having them removed from the abusive situation to prevent further injury if necessary.
• Know whom to notify locally to report the suspected abuse.
• Carefully document any statements made by the parent or caregiver or child, or both.
• Have a list of accessible forensic medical examination sites, including maps for reaching them.
• Explain why the forensic site is the best place to take the child.
• Provide the caregiver with information about the sites as to what to expect, exam components, how long it will take, and costs etc.
• Assure the caregiver of the provider's availability to listen and help answer questions following the exam.

Future Actions to Consider

Often a report of possible abuse serves as a "wake-up call" for the community or primary care provider. It should prompt some reexamination of actions that can be taken to prepare the clinical setting and the community to combat this problem.

Some steps for health care professionals to consider:

• Incorporating screening for parental history of abuse, whether abuse as a child or domestic violence, as part of child health exams
• Identifying at-risk families and referring early to social service agencies. At-risk families include those with any of the following characteristics:
1. Prior history of child maltreatment
2. Lack of emotional attachment to the child
3. History of infant or child death that may have been from maltreatment
4. Isolated caregiver who lacks a social support network
• Establishing closer primary care supervision and sick child follow-up of at-risk families and children
• Initiating formation of, or joining, a community team to work with families at risk

Following an incident of suspected child sexual abuse, the involved health care professional may choose to expand her/his knowledge and education in order to serve other children in the community in the future. Some choices to make may include:

• Preparing as a SANE (sexual assault nurse examiner) investigator
• Obtaining education as a forensically sound interviewer to testify to the courts
• Providing community education on recognizing child abuse and how to prevent it
• Incorporating anticipatory guidance in the wellness exam that addresses caregiver awareness of early signs that her/his child might be a victim of abuse.

Health care professionals should be aware of current research findings on care for the abused child and the information should be shared within the agencies where they work. As an informed community member a provider can be a patient advocate and assure that the parent and child are afforded the best opportunity for receiving an exam in the nearest center equipped to perform a thorough forensic examination. At the same time, the family is assured of having any possible evidence collected and protected properly for the legal system to use for prosecution of the perpetrator.

So what is the compelling physical evidence that will provide enough ammunition to successfully prosecute the perpetrator? At this point in discovery, that can only be determined on a case-by-case basis. It will generally require a number of variables including; the quality of the history and the child's ability to tell the story in a compelling manner, in addition to other ancillary evidence collected that has led to convictions (De Jung & Rose, 1989).

The important information needed by the nurse or community health care provider who has not been specifically educated to examine for signs of abuse is "don't". Any attempt by the nurse, however compassionate and well-intentioned, to provide a cursory "check up" exposes the child to unnecessary intrusion on their privacy and delays access to appropriate care. It may also remove or contaminate potential evidence needed to convict the abuser.

References

Adams, J., Harper, K., Knudson, S. & Revilla, J. (1994). Examination findings in legally confirmed child sexual abuse: It's normal to be normal. Pediatrics, 94: 310-317.

Aiken, M. (1990). Documenting sexual abuse in prepubertal girls. Maternal/Child Nursing, 15:176-177.

Behrman, R., & Kliegman, R. (1998). Nelson Essentials of Pediatrics, 3rd Ed. Philadelphia: W.B. Saunders.

Berenson, A., Somma-Garcia, A., & Barnett, S. (1993). Perianal findings in infants 18 months of age or younger. Pediatrics, 91(4): 838-840.

Burns, C. et al. (2000). Child Maltreatment. In Pediatric Primary Care: A Handbook for Nurse Practitioners, 2nd Ed. Philadelphia: W.B. Sauders.

Cantwell, H. (1983). Vaginal inspection as it relates to child sexual abuse in girls under thirteen. Child Abuse & Neglect, 7:171-176. DeJong, A. & Rose, M. (1989). Frequency and significance of physical evidence in legally proven cases of child sexual abuse. Pediatrics, 84(6): 1022-1026.

Emans, S. et al. (1987). Genital findings in sexually abused symptomatic and asymptomatic girls. Pediatrics, 79 (5):778-785. Flournoy, J. (1996). Incest prevention: The role of the pediatric nurse practitioner. Journal of Pediatric Care, 10(6): 246-254.

Gardner, R. (1993). Medical findings and child sexual abuse. Issues in Child Abuse Accusations, 5(1):12-23.

Hobbs, C. & Wynne, J. (1989). Sexual abuse of English boys and girls: The importance of anal examinations. Child Abuse & Neglect, 13:195-210.

Krugman, S., Wissow, L., Krugman, R. (1998). Facing facts: Child abuse and pediatric practice. Contemporary Pediatrics, 15(8): 131-144. McCann, J. et al. (1990). Genital findings in prepubertal girls selected for nonabuse: A descriptive study. Pediatrics, 86(3):428-439. Reece, R. (1994). Child abuse: Medical diagnosis and management. Philadelphia: Lea & Febiger.

Robinson, D. & McKenzie, C. (2000). Determining sexual abuse in children and adolescents. In Procedures for Primary Care Providers. Philadelphia: Lippincott.

Sexual Assault Training Program Focus on Pediatrics. Atlanta: Scottish Rite Children's Medical Center, February 17-21, 1997.

White, S., Ingram, D., & Lyna, P. (1989). Vaginal introital diameter in the evaluation of sexual abuse. Child Abuse & Neglect, 13:217-224.

Wong, D. (1999). Child Maltreatment. In Whaley & Wong's Nursing Care of Infants and Children, 6th Ed. St. Louis: Mosby.