Hello and welcome to the Pediatric Medical Forensic Examination Essentials for the Forensic Nurse. My name is Gail Horner. I'm a Forensic Nursing Specialist at the International Association of Forensic Nurses. Prior to working at IFN, I worked as a Pediatric Nurse Practitioner in a hospital-based child advocacy center and also coordinated a pediatric sexual assault nurse examiner program for 28 years. The authors, presenters, and planning committee for this educational offering have no relevant financial relationships to disclose. For the next hour or so, we will explore indications for the medical forensic examination, describe anogenital exam techniques, take a look at normal and abnormal anogenital findings, and discuss sexually transmitted infections and child sexual abuse. So, we all recognize that child sexual abuse is a pediatric health care problem. According to the U.S. Department of Health and Human Services, there were nearly 600,000 victims of child maltreatment in the United States in 2022. The majority of the children, 74 percent, suffered neglect, 17 percent physical abuse, nearly 11 percent sexual abuse, 6.8 emotional abuse, and 0.2 percent sex trafficking. So, there were approximately 60,000, just under 60,000 victims of sexual abuse that were identified in the United States in 2022. And keep in mind, that number, these official numbers, are really only the tip of the iceberg. It represents cases of child maltreatment that are, first of all, reported to Child Protective Services. Child Protective Services makes the decision to investigate the concern, and Child Protective Services is able to substantiate the concern. Again, this official number is only the tip of the iceberg. We know that many cases, if not most, of the cases of child maltreatment are never reported to Child Protective Services. And when considering sexual abuse alone, retrospective studies of adults have revealed that one in five victims of child sexual abuse never disclosed their victimization. Take a look at the consequences of sexual abuse. The physical consequences make sense. Bruises, abrasions, other non-genital injuries can occur, although really violent child sexual abuse resulting in non-genital injuries are very rare. Anogenital injuries can occur, although overall, in less than 10% of the cases of child sexual abuse, are there any physical findings upon anogenital exam? Sexually transmitted infections, less than 5% of children who are sexually abused will contract a sexually transmitted infection. And pregnancy, thankfully, resulting from child sexual abuse is relatively rare. Certainly, the emotional consequences can be significant as well. Post-traumatic stress disorder, depression, anxiety, the development of high-risk sexual behaviors. These kids are at increased risk for entry into human trafficking. They can exhibit a variety of behavioral concerns. And self-harm and suicidal ideation can also develop. But look at the long-term consequences of child sexual abuse. Heart disease, liver disease, chronic lung disease, diabetes. Why would these things, why would these diseases develop as a result of sexual abuse? The Adverse Childhood Experience Study is a landmark study that solidified our knowledge that psychosocial traumas in childhood have a direct effect on adult health, both mental and physical, in a dose-related gradient. So, in the Adverse Childhood Experiences Study, 18,000 adult members of the Kaiser Permanente healthcare plan were surveyed regarding their childhood experiences. Child maltreatment, physical abuse, emotional abuse, sexual abuse, neglect, domestic violence, mental illness, household domestic violence, household mental illness and substance abuse, parental separation and divorce, household criminal member. And then they were also surveyed regarding their adult health behaviors, diet, exercise, substance use, and adult health, both mental and physical. And what was found was that adverse childhood experiences were very common among the study population, with more than two-thirds of the study participants reporting exposure to at least one adverse childhood experience. And exposure to many ACEs was also very common. In fact, if an individual reported exposure to one adverse childhood experience, 87% of those individuals reported exposure to at least one additional ACE, and 52% reported exposure to additional three to four ACEs. That lets us know, first of all, that child sexual abuse rarely occurs in isolation, that it oftentimes occurs with other adverse childhood experiences. And also the adverse childhood experiences study told us that the higher number of ACEs an individual reported than the poor adult health behaviors and poor adult health outcomes, both physical and mental health outcomes. We all know that exposures to trauma can result in stress, and we realize that not all traumatic events are equal in the stress that they produce. Think about the stress that a child undergoes who experiences sexual abuse. Whether or not there's domestic violence or physical abuse going on, the sexual abuse alone is a unique trauma. Stress is not always unhealthy, but stress that becomes chronic and or unpredictable becomes toxic stress. Think of little Janie, who is sexually abused by Uncle Jim. She never knows when Uncle Jim is going to come over and bad touch her. She never knows when Uncle Jim is going to come over and bad touch her. This is stress that becomes chronic and unpredictable. And therefore, the chronic stress response of the body becomes activated. Our body reacts physiologically to both physical stress and psychological stress. So, when we're talking about chronic stress, we're talking about toxic stress. We're talking about the activation of the hypothalamic pituitary adrenal axis. We are talking about release of cortisol and cytokines. This results in dysregulation across multiple biologic systems. We have increased cortisol, which is going to suppress the immune system and cause long-term health problems. We have metabolic issues. Increased cortisol is going to increase the metabolic rate. And then we have changes to the nervous system. We know that brains are not completely developed until about age 25, that the myelination and refinement of neural networks occurs over decades. And consider this, the brain is not mature at birth. And in fact, it triples in size from birth to age five. So, consider for a second, the effect of these adverse childhood experiences in the really young child, in early childhood, zero to age five. Because these changes in the nervous system actually cause changes in the brain and how the neural pathways are laid down. Let's talk about some different parts of the brain. The prefrontal cortex is a part of the brain responsible for planning, for intelligent insight, for judgment. The hippocampus is the part of the brain responsible for memory storage and retrieval. The amygdala is responsible for the autonomic response to fear and survival. The nucleus acubans is the part of the brain that kind of smooths stress out. It creates equilibrium. It's the area of the brain for cognitive processing of aversion, motivation, pleasure, and addiction. So, consider these children that are exposed to adverse childhood experiences. Consider a child who's been sexually abused. And consider the changes in the brain. Do you think it's the prefrontal cortex and the hippocampus that's getting all the neuronal pathways laid down? No, it's the amygdala and the nucleus acubans. And in fact, it is thought that exposure to sexual abuse and the other adverse childhood experiences are probably the number one risk factor for the development of addictions. Now, let's talk about the medical forensic examination. And we'll primarily focus about the exam in the prepubertal patient. This is a reference that every pediatric forensic nurse should really keep handy and rely on for interpretation of medical findings. This is an open access article. So, if you just Google it, you can download and print out and save the article. If you have any difficulties please email me, and I will assist you. Indications for the medical forensic exam. And this is really true whether you're pubertal or prepubertal. Some indications for completing the medical forensic exam include the history given by the child. Is the child giving a history of sexual abuse, be it genital-to-genital contact, anagenital contact, oral genital contact, or fondling? That child needs a medical forensic exam. Are there anagenital symptoms, such as bleeding, pain, discharge, bruising? Does the caregiver have concerns of sexual abuse? Are there situational factors that raise concerns, such as another individual observed the sexual abuse of this child? Does the child have a sexually transmitted infection? Has a perpetrator confessed to sexually abusing the child? The medical forensic examination includes a head-to-toe assessment. And this is really important for children, because their health care may be sporadic. There may be previously undetected acute or chronic health care concerns, like a heart monitor, heart murmur, or otitis media, or a strep throat. And we can provide treatment for acute health care concerns. And then also we can relink or link the patient with needed specialty care. Perhaps we did note a heart murmur, and it's never been previously detected. We can refer that child to cardiology. Or I've also performed exams on kids that were diabetic that had lost contact with endocrinology, and they were relinked with endocrinology. We can also assist in linkage for the child with a primary care provider. And then also the head-to-toe assessment is important to document non-genital trauma. The anogenital exam is a crucial aspect of the medical forensic examination. The majority of time, we are providing reassurance to the child and the family that their body is normal, despite what has happened to them. And of course, this reassures the caregiver immediately. But many children, even children as young as five or six, have expressed such relief in knowing that their bodies are okay, despite what has happened. Anogenital exam can also reveal an anatomical finding that is not related to trauma or sexual abuse, but needs further follow-up by a specialist. And also an acute or chronic anogenital finding concerning for trauma may be revealed, or a sexually transmitted infection. Some myths about the anogenital exam. Number one, that it's painful. We all know having done these exams, there's really nothing painful about the exam. I'm not saying that the child can't feel embarrassment and discomfort with the exam, but nothing about the exam is really painful. There's a perception that the exam is traumatic to the child. A number of years ago, I conducted a study with some partners looking at the emotional response to the anogenital exam. And we looked at 246 children between the ages of eight and 18. And they had to be old enough to be able to complete the anxiety scale. And 83% did not report clinically significant anxiety before or after the child sexual abuse exam. You will also hear law enforcement, child service, or child services perhaps say, this exam is unnecessary. She just said she was touched. Well, there are certainly, we all know that disclosure is a process. And maybe with the initial disclosure, the child is talking about fondling under clothes, and we're not expecting to find any anogenital finding. But we all know that disclosure is a process and that perhaps additional things happen to the child. And that it's important for that child to have an anogenital exam. Another myth is that the exam is an expense for the family when the Violence Against Women Act has solidified the fact that the state or another entity must pay for the medical forensic exam. Now I'm just going to briefly talk about forensic evidence collection and just kind of talk about in our Child Advocacy Center and Emergency Department, we adopted a very inclusive criteria for evidence collection. It had to be within the timeframe set by the state. In the state of Ohio, it was 72 hours for children 15 years and younger and 96 and then now pushed to 120 for children 15 years of age and older. So within timeframe, a history of sexual abuse given to the caregiver or to the medical or given in the forensic interview or the medical forensic history. And this history could include genital to genital contact, anogenital, oral genital, fondling of the breast, genitalia, or buttocks under clothing. We collected evidence for all of those disclosures. And other credible high-risk concerns, even if the child is not giving history, such as an abduction or confession of a perpetrator. A sexually transmitted infection in a pre-pubertal patient. Now, if the patient was eight years old, said her father sexually abused her, the last time she saw her father was a month ago, we would not collect evidence in that case because clearly this incident is out of timeframe. But most often in pre-pubertal patients who test positive for a sexually transmitted infection, oftentimes, unfortunately, they do not disclose a history of sexual abuse. And so we recommend evidence collection because that patient may still be actively being sexually abused by that perpetrator. An unexplained acute genital or anal injury triggered evidence collection. And there were times that law enforcement would request. Let's talk a bit about forensic evidence yield. In 2011, Thackery and company took a look at 388 evidence kits of children aged zero to 20 years. 25% of the process kits were positive. 65% produced identifiable DNA. 10% of those children whom their rape evidence kits produced identifiable DNA gave no history of sexual abuse in a forensic interview. Factors that were found to be associated with increased DNA yield included evidence collection within 24 hours of abuse. Although evidence was found on a body up to 54 hours after the latest incident of sexual abuse. Children giving history of genital to genital or genital anal contact, not bathing or changing clothes, a perpetrator older than 18 years of age and anal genital exam findings. Forensic evidence yield in this study also, nine children yielded forensic evidence findings that were not expected on the basis of their disclosure. The three-year-old who disclosed digital genital contact and kissing was found to have semen in her vagina and underwear. Eight children who denied perpetrator ejaculation were positive for semen. Nine children tested positive for amylase with digital anal and or digital genital contact and no reported oral contact. Another study to be published in 2022, we looked at 306 evidence kits from children aged 0 to 18 years. 36 percent of the evidence kits yield interpretable foreign DNA. The factors that were associated with increased forensic yield were increasing age of the child victim. 48 hours or less since abuse, and this is a big difference from previous studies where the 24-hour mark from latest incident of sexual abuse was the marker for increased yield. In this study, it was up to 48 hours. Child disclosing high severity acts like genital to genital, or oral genital, sex abuse by a non-relative perpetrator. When you look at these factors associated with increased forensic yield, we realized that failure to collect evidence in a child who did not disclose sexual abuse, and yet there were other circumstances that raised concern for sexual abuse, could result in a loss of possible forensic evidence. Now we'll talk about the anogenital exam. So, to complete a thorough and competent anogenital exam of the prepubertal patient, basic knowledge of normal anatomy is necessary. So, take a minute to label this slide with, you know, like which letter is labia majora. So, take a minute to do this. So, here are the correct answers, and I'll give you a minute to kind of look through your answers. Some anogenital techniques before the exam. Explain to the child and the caregiver exactly what is going to happen. Show them the colposcope or the cortex flow. Show them the instrument that you use for photo documentation of the exam, and use the anogenital exam as an opportunity to educate the child and the parent regarding body safety. Talk to them about private parts, have them identify their private parts, and talk to them about how no one should touch, tickle, look at, or hurt their private parts, and what should they do if someone does. Should they tell or keep it a secret? And then, if they don't, if someone does, should they tell or keep it a secret, and who can they tell? So, the anogenital exam really does offer a wonderful opportunity to provide some basic education regarding body safety. Different positioning can be utilized. Supine position. Honestly, the majority of the time, we, even in young children, use the stirrups, and we call them footholders, and examined in that position. You can also use the frog leg position. Young kids, oftentimes, it might be easier to examine them when they're laying in their caregiver's lap. Knee-chest position is typically only used when you're needing to verify a finding that you found in supine position. You want to flip the child over into knee-chest to verify the finding, but you can use that for your initial exam as well. Some techniques for hymens that won't open. We all know there's traction where you're pulling the labia versus separation. Sometimes, just separating the labia will do, especially if the patient has a very anterior hymen, but sometimes, especially maybe if the patient's a little fuller, you need to use traction to separate. If it won't open, try squishing and retraction. You can pull that traction pretty far without hurting the child. Sometimes, it's necessary to reposition the child, have the child move around a little bit, and then try again, and the hymen will open for you, or you can float the hymen with normal saline, and then typically, it will open. And these later two, the palpation, are only used in pubertal females. Q-tip can be used to palpate the hymen and the Foley catheter. When interpreting anagenital exam findings, it's important to be familiar and use the ADAMS criteria. It's kind of the gold standard for the interpretation of the anagenital exam, and I have the complete reference for the ADAMS article at the tail end of the presentation. She classifies findings as normal variant, caused by medical conditions, not trauma, often mistaken for sexual abuse, no expert consensus, meaning child abuse pediatricians were shown photos or videos of exams with certain findings, and some of the child abuse pediatricians felt that they were concerning for sexual abuse, but others did not, and then findings caused by trauma, acute and chronic. Now, we'll talk a minute about normal variants. You see the annular hymen, where there is hymenal tissue, 360 degrees around the hymenal opening. Here, we see a crescentic hymen, where there's no hymen from, oh, probably about three, or that would be nine, nine to three o'clock. We also have a dilated urethra, which is also a normal variant, and then we see hymens on the posterior or anterior rim of the hymen. There can be bumps anywhere, and here we see a bump at about five o'clock. Shallow notches or clefts in the hymen are normal variants. Here, we see a shallow notch at three, at nine o'clock, and unless this notch would extend entirely through the hymen, it is not a physical finding concerning for sexual abuse. The findings that there is inconsistent consensus, one of them is a notch, and we're talking about non-acute notches. Acute notches are concerning whether they're complete or partial, but say a notch that extended to here, but we can clearly see there's hymenal tissue remaining. That, again, is that no expert consensus category. Here, we see a crescentic hymen with a mound or a bump at like four o'clock. In the picture on the right, we see a vaginal ridge attaching to the hymen at about six o'clock. Picture on the left, you see a hymen floated with normal saline. It opened up to reveal a very delicate normal hymen with a mound or a bump at like 530, six o'clock. And then on the right, you see a transparent hymen. It's almost as though you can see through the hymen. Hymenal tags are a normal variant that can attach anywhere along the anterior or posterior rim of the hymen. They could be remnants of a hymenal septum, however, it's impossible to say. I mean, this tag is coming from about 12 o'clock. It could be a septum remnant, but we really couldn't say that unless the child was examined previously and a septum was documented. Now, the photo on the right with the multiple small hymenal openings is referred to as a cribiform or sieve-like hymen. This child needs a referral to pediatric gynecology because there would be a concern for duplication or other anatomical problems within her reproductive tract. Here are examples of septate hymen. The concern with a septate hymen is that the septate hymen could go all the way back through the vagina and you could have duplication of the vagina and the reproductive tract, so you need to be able to visualize behind that septum or pass a Q-tip behind the septum, and if you cannot do so, then that child requires a referral to pediatric gynecology. The figure on the left, most likely you could pass a Q-tip behind that, but if you feel uncomfortable doing that because this is a young child and you're afraid of hurting them, even with this septum, you should refer to pediatric gynecology. The hymen septum on the right, I would definitely refer to pediatric gynecology because it does look as though that septum could extend into the vagina. This is an example of a septate hymen in an adolescent, and you can see I was very easily able to pass this Q-tip behind the septum, so no concern for duplication of the vagina and the reproductive tract. However, septums can cause problems with tampon insertions. Tampons can get stuck in the vagina and can cause difficult initial sex, so this is a child that you might, this is a teen you might want to go ahead and refer to gynecology so that they can evaluate whether or not this septum should be cut prior to the onset of sexual intercourse. Microperforate hymen, very small hymenal opening, or imperfect hymen, no hymenal opening, both of these patients need to be referred to pediatric gynecology. The microperforate, obviously, sexual intercourse would be very painful, very difficult, and it might be, given the location of this microperforate opening, difficult for menses to expel the body. Imperforate hymen, once this girl starts having periods, there will be no way for the menses to expel from the body, and the child will experience, you know, severe abdominal pain and discomfort, and that is an example of an imperfect hymen that child entered adolescence, it had never been discovered, and now she has a bulging hymen. Some midline defects. Failure of midline fusion you see that area between the vagina and the anus can be mistaken for a laceration, an acute finding of sexual abuse. Many parents, obviously, these perineal grooves have been there since the child was a baby, but they just never noticed it, and then when there's a concern for sexual abuse, the parent is like, well, that was never there before. I mean, one thing you can do is touch it with a Q-tip. If it doesn't hurt, it's probably not a laceration, and then also have the child come back in a week or two, and if it looks the same, then obviously it's a failure of midline fusion. It is not an acute laceration. This slide just kind of shows us the estrogen effect on the hymen. You see in a newborn, and then you also see in adolescence. Once a child enters adolescence, the hymen, due to estrogen, the hymen is no longer sensitive to touch. The hymen has increased elasticity. All of the genital structures do. It's moist. It's the body preparing itself for sexual intercourse, so it's normal to be normal. A normal anogenital exam does not negate the possibility of sexual abuse, and this is for several reasons. First of all, all of the acts that the sexual abuse acts that a child may experience, we wouldn't expect to find any physical findings, such as fondling of the breast, genitalia, or buttocks, or oral genital contact, a mouth to a vagina or anus. You wouldn't expect any physical findings, and then elasticity. The genital structures, even in the prepubertal child, are somewhat elastic to allow some penetration without tearing, but certainly once a child enters adolescence, then the estrogen effect really increases elasticity of the hymen and the other genital structures. Prepubertal sensitivity also may be protective against anogenital injury in the young child. If you think about it, when we used to have to test for chlamydia and gonorrhea via culture, and I would have to pass Q-tips through the hymen opening of prepubertal girls, and the child would move, and I'd actually touch the hymen, it hurt, and the child let me know it hurt. I think that's probably what happens when these children are being sexually abused. There's penetration of the labia to the point of touching the hymen. The child indicates it hurts, and the perpetrator doesn't want to cause injury because it doesn't want to cause bleeding and risk being detected. Also, the perpetrator doesn't want to hurt the child because the perpetrator wants the child to engage in this behavior again. Then also, healing. The anogenital structures heal very quickly, most often without scarring. A number of years ago, I saw a nine-year-old girl in the emergency department, and she gave history of sexual abuse by her uncle. She had a tear of the posterior forceps. She had a tear in her hymen that extended through the base of the hymen, bruising on the hymen from about three to nine o'clock. Clear evidence of acute anogenital findings that are diagnostic of sexual contact and consistent with the child's history of sexual abuse. Then I saw her back two weeks later because the mother was concerned about, she had some bumps and mama's concerned she might have herpes. She didn't have herpes, but the posterior forceps laceration had torn without any scarring. Transsection of the hymen had healed. There was just a shallow notch. Of course, the bruising of the hymen had gone away. If I had examined that little girl for the first time two weeks after her sexual abuse, I would have said that she had a normal, nonspecific anogenital exam. Findings caused by other medical conditions. So when considering ADAMS criteria for interpretation of the anogenital exam in relationship to child sexual abuse, there are findings commonly caused by conditions other than trauma or sexual contact. Erythema, inflammation, fissuring maceration of the tissue, nonspecific, increased vascularity of the vestibule and hymen, labial adhesions, friability of the posterior forceps. It is a nonspecific finding and we as examiners know that we have to pay heed to the amount of separation and traction we are applying so that we do not cause a tear of the posterior forceps. Vaginal discharge can be caused by several different entities, including sexually transmitted infections, but other causes as well. Anal fissures, perianal venous congestion, and complete immediate anal dilatation with predisposing conditions. Labial adhesions are not caused by sexual abuse. The photo on the left, the exam photo on the left, I might treat that, I might not. Looks like there's an adequate opening for the child to urinate out of. The exam on the right, I would definitely treat. Those labial adhesions are so severe that it's hard to say. I would think that child would be symptomatic, would be experiencing some dysuria and discomfort. And the treatment is with estrogen cream, with Premarin. You want to apply lightly to the affected area. I usually show the parent right on the colposcope photo. We had a monitor in the room so you could show them. Apply it very lightly with a Q-tip along this line, the adhesion line. Because if you apply it too heavily, child can develop some sexual characteristics like breast buds, might even start having some pubic hair. So you want to urge them to apply it, but to apply it lightly. Twice daily for two weeks, and then once daily for two weeks. And then return to the primary care provider to make sure that the adhesions have opened up. If they do not have a primary care provider, they could return to see you. Venous pooling is just a variation of normal, can be mistaken for bruising, but it is just venous congestion. Anal fissures are superficial tears of the anal skin. And according to Adam's criteria, can be caused by conditions other than trauma, such as constipation or diarrhea. Findings mistaken for abuse. So there are findings that you may note on anogenital exam that are due to other conditions which can be mistaken for sexual abuse, such as the irritation, erythema, inflammation, fissuring. Inflammatory causes, such as atlas ulcers, inflammatory bowel disease, bichettes, which can result in painful ulcers, dermatological conditions, immunologic conditions, urethral prolapse, rectal prolapse, and anal fundling, also post-mortem changes, can be mistaken for sexual abuse. Post-mortem findings such as anal dilatation, red-purple discoloration of the genital structures, including the hymen, from lividity or other rare systemic conditions. Urethral prolapse. You get called into the ED for that three-year-old. That has vaginal bleeding. It's not giving any history of sexual abuse. Mom doesn't have any concerns for sexual abuse. And you go into the exam and this is what you see. Oftentimes, there are, I don't know why, more common in African-American girls. It is more common in chubby girls and girls with a history of constipation. Constipation makes sense because of the straining. Urethral prolapse typically requires a referral to urology. I would recommend SITZ-BAS. It eases the discomfort. And estrogen cream to the affected area, BID times two weeks. Lichen sclerosis is oftentimes mistaken for acute injury related to sexual abuse. Lichen sclerosis, the real cause is not really known. It's thought to be an autoimmune disorder. It's found in postmenopausal women and prepubertal girls. And you see, note the hypopigmentation from the vulva down to the anus. And then you see the areas of subepithelial hemorrhages. Subepithelial hemorrhages. This can also be itchy, so the child can scratch. And you can see some irritation and some bleeding. And again, you can certainly understand the concern how lichen sclerosis can be confused for acute injury, acute like bruising, petechiae, but it is indeed lichen sclerosis. And really the key is that hypopigmented area from the vulva to the anus. Once you see lichen sclerosis, you'll never confuse it, but the first time you see it, it can be a bit shocking and confusing. Strep butt. So you can have strep butt infections, also strep vaginitis. This beefy red look is diagnosed by culture and is treated with amoxicillin. Fistula of the posterior forcette. Requires a referral to pediatric gynecology. This is not trauma related and it's a very rare finding. No expert consensus. So these are findings, like I said, that could kind of go either way, but at this point, we cannot say that they are concerning for trauma. Complete anal dilatation. Relaxation of the internal and external sphincters. And I think that this is probably in the no expert consensus because it's kind of vague and it's kind of a difficult, it's difficult to say both the internal and external sphincters are relaxed, but again, it's no expert consensus. Hymenal notch or cleft at or below the three and nine o'clock position. And again, these are non-acute hymenal notches at or below the three and nine o'clock that extends not entirely to the base of the hymen, but nearly to the base of the hymen. I was kind of showing you that earlier. This needs to be confirmed in another position. And again, there's no expert consensus. And you, if you see this finding, and again, these are non-acute for the hymenal notch or cleft at or below three and nine o'clock, the complete cleft to the hymen at three and nine o'clock. These are non-acute findings that we're talking about. Because if you find an acute hymenal notch or cleft, I don't care if it's at three and nine o'clock and I don't care if it's a partial, it is concerning for trauma. But anyway, these non-acute partial notches or clefts or the complete cleft at three and nine o'clock, no expert consensus. So on your report, you could say there are no expert consensus. There are experts that consider it concerning for trauma, and there are other experts that do not, but you certainly cannot call it a finding concerning for trauma. Findings caused by trauma. They can be acute, they can be residual or non-acute. Acute laceration or bruising of the penis, scrotum, labium, or perineum. And I apologize, I have no photos of exams of bruising to the penis and the scrotum, but certainly if you see those, those are findings caused by trauma, child needs a rape evidence kit, child needs tested for sexually transmitted infections. However, probably most likely, oftentimes bruising to the penis and scrotum are related to physical abuse more than sexual abuse. However, you need to, the child needs an acute evaluation for child sexual abuse. Acute laceration of the posterior brochette, acute hymenal laceration of any depth, vaginal laceration, perianal laceration with exposure of tissue below the dermis. And then residual findings include perianal scar, which are difficult to diagnose unless the child was seen acutely and had had an acute anal scar. Scar of the posterior brochette, again, hard to diagnose unless the child had been seen acutely and an acute laceration of posterior brochette was noted. A healed hymenal transection with areas of missing hymenal tissue. Again, this needs to be complete, the hymenal transection needs to be complete to the floor of the vagina and an area of missing hymenal tissue. And then female genital mutilation. Here are some photos of acute injury. This is a four-year-old patient that presented to the emergency department pulseless and non-responsive. She was, her resuscitation was successful and she was intubated and transferred to the PICU. The SANE nurse, the anogenital trauma was noted and the SANE nurse was called in to see the patient. And these photos are excellent and they were taken with a handheld, just small 35 millimeter camera. So in this photo, you see anal lacerations, much different than those anal fissures that I showed you before. This child has multiple anal lacerations at six, four, seven. There's also bruising about the anus. Bruising of the labia. And you begin to see a perineal laceration between the vagina and the anus. The perpetrator was mom's boyfriend and he admitted to inserting a dildo into the anus and trying to insert it into the vagina. But he said it wouldn't fit. So you see the bruising on the labia and also by the labia minora there. Again, acute anogenital injuries. You can see acute injury to the urethra and the hymen in this photo. And again, you see that very obvious perineal laceration. Again, some other photos of the hymen showing the bruising. This child also had a bowel perforation and it was surgically repaired and she recovered and is doing well. Here's some additional photos showing the acute trauma. This is another child with acute trauma. This was an 18-month-old that was playing in a bathtub. Mom was right there with her. She had like cups and funnels and the little girl stood up and then she falled on an inverted funnel. And there we see normal hymen, but we see a laceration and hematoma of the posterior foreshad and bruising about the posterior foreshad. Other examples of acute trauma. Bruising of this hymen on the left from, it looks like from three to six o'clock, a transection there at five o'clock. The picture on the right, you see a large hematoma from about what? 10 o'clock to one o'clock. Bruising from one o'clock to five o'clock, a transection at like four o'clock. Acute injury. And these are pubertal patients and thus the Q-tip. You see bruising to the vaginal wall and bruising to the hymen with a laceration at, or transection at seven o'clock. And then the photo on the right shows hymenal bruising from about three to five o'clock. Other acute trauma. On the left, you see an acute transection of the posterior foreshad. And then on the right, you see an acute hymenal transection at six o'clock that's beginning to heal. This was at the 72-hour mark. In adolescent patients, it shows the importance of palpation of the hymen. And then on the left, the non-palpated hymen, you really can't see any acute injury, but with palpation, you'll see that there is indeed an acute transection. Looks like it extends almost totally through the hymen and there's some active bleeding. Small amount of active bleeding. Healing or residual injuries. This is a six-year-old. She has precocious puberty, by the way, because you see the pubic hair. This is a six-year-old that was being seen due to sexualized behaviors. She was interviewed. She gave no history of sexual abuse in her forensic interview. She'd also been in foster care and in multiple foster care placements. But you see, clearly see, a non-acute hymenal transection at six o'clock with missing hymen from about 5.30 to six o'clock. And then you flip her over into knee chest and that physical finding remains. And with non-acute hymenal transections, it is important to confirm the finding in another position. These are some other examples of healing injuries in adolescents. They both demonstrate a complete transection at six o'clock. Again, you would flip her over to confirm this unless she was sexually active and therefore the hymenal transection had no forensic value. But if she was not sexually active, then certainly there could be forensic value to this finding. This is an example of female genital mutilation. You have fusion of the labia minora and the clitoris has been fused and yet the hymen is perfectly normal. New to the 2023 ADAMS criteria is the addition of intraoral injuries in children presenting with a concern for penile penetration of the mouth. And you see any unexplained oral injury, particularly injury or petechial hemorrhage of the palate, particularly at the junction of the hard and soft palate and bruises or abrasions or petechiae to the lips. Findings diagnostic of sexual contact. Pregnancy and sperm identified from the forensic specimen taken from a child's body. So in pregnancy, if this is a child beyond the age, below the age of legal sexual consent in your state, it's very important to identify the source of the pregnancy, how the pregnancy occurred. I mean, even in any teen, it's important to talk about that, but especially in a child below the age of sexual contact, legal sexual activity. We'll talk a bit about infections. According to the 2023 ADAMS criteria, listed on this slide are the indications for sexually transmitted infection testing. Any child who gives history of oral, anal or genital penetration by a penis, this would also include any child with unexplained oral, anal or genital injuries, acute injuries, a child sexually abused by a stranger or the perpetrator is known to be infected with a sexually transmitted infection or known to be at high risk, such as an individual with multiple sexual partners, a man who's known to have sex with other men, an individual who's been to prison or uses IV drugs, a sibling in the home or another child in the home, pre-pubertal sibling or child we're talking about with a sexually transmitted infection, such as chlamydia, gonorrhea, trichomonas, but also syphilis and HIV. Child makes a disclosure of sexual abuse and lives in an area that has a high prevalence of sexually transmitted infections. A child with symptoms of sexually transmitted infections, such as genital discharge, should be in the differential diagnosis of that child with vaginal or anal discharge, sexually transmitted infection should be in the differential diagnosis. And along with perhaps other testing, such as a general bacterial culture of the genital area, there should also be testing for sexually transmitted infections. If the child is diagnosed with one sexually transmitted infection, such as chlamydia, they should be tested for other sexually transmitted infections. Or if the child or the parent requests testing for sexually transmitted infections. If the child is unable to verbalize the assault and yet there's reason to believe that sexual assault occurred or this sexual abuse was witnessed or photographed, these are all indications for sexually transmitted infection testing. This chart just kind of shows indications for sexually transmitted infection testing. If the child gives history of genital to genital contact, has an unexplained genital injury or genital discharge, you should obtain a urine. If it's a pre-pubertal female or a male of any age, it would be a urine gnat for Chlamydia gutterea trichomonas. If it's a pubertal female, the vaginal gnat has a slightly increased sensitivity over the urine gnat. So you may want to obtain a vaginal gnat rather than a urine gnat in an adolescent female. That child also needs to have serologies completed for HIV, syphilis, hepatitis B and C. If there's concern of anogenital contact, unexplained anogenital injury or anal discharge, then an anal gnat for Chlamydia and gonorrhea should be completed. Or a culture if your facility does not complete extra genital gnat testing. That child also needs tested for HIV, syphilis, hepatitis B and C. Oral genital contact, victim to perpetrator's genitals or anus. That child needs an oral gnat for Chlamydia and gonorrhea. Oral genital contact, perpetrator to victim's genitals. That patient needs a urine gnat for Chlamydia gonorrhea or if it's a pubertal female, you might want to obtain a vaginal gnat instead of the urine gnat. And for oral anal contact, perpetrator to victim's anus, an anal gnat or culture for Chlamydia and gonorrhea. This is the algorithm for syphilis testing. I just wanted to kind of show you this because the gnat testing, the genital gnat testing and the anal and oral gnat testing have a built-in like confirmatory test within there, within the test. And for syphilis, this is the testing logarithm. If you, first you're gonna initially test with a non-TREP test like RPR or VDRL. If it's non-reactive, they don't have syphilis, you don't need to do anything else. If it's reactive, then they need a TREP test. They need an EIA or a CLILA done. And if it's non-reactive, they do not have syphilis. If it's reactive, they do have syphilis. So the syphilis testing is a little bit more complicated. This table explains interpretation of a positive sexually transmitted infection result. What does a positive STI result mean in relationship to sexual abuse? A child who tests positive for genital anal or oral gonorrhea or genital anal or oral chlamydia or genital trichomonas. These infections are transmitted by sexual contact unless there is evidence of perinatal transmission or clearly documented but rare non-sexual transmission. When we're talking about gonorrhea, perinatal transmission typically clears in the neonatal period. So by one month of age, gonorrhea, whether or not it's been treated, genital anal or oral gonorrhea should have cleared. Chlamydia and trichomonas, the window may be a little bit longer. Some studies show up to three years, but again, there has to be clear evidence of perinatal transmission. So in a three-year-old with chlamydia, one would still assume transmitted by sexual contact unless clear evidence of perinatal transmission can be documented, such as a child having genital discharge for three years. Then perhaps, and it's documented in the medical record, and the child was just never tested for chlamydia, then perhaps you could link it, and it's known that mom had chlamydia during pregnancy, then perhaps you could link it to perinatal transmission, but again, there has to be clear evidence. And when we talk about rare non-sexual transmission, we're not talking about from the bathtub or the toilet seat. I will share on one occasion, I had a parent of a young child, I think she was three, who the mother told me that she was diagnosed with chlamydia and at the time she really didn't know that she had chlamydia, but she was having genital discharge and irritation, and she went to the toilet, wiped herself, and then the child went to the toilet and the mother wiped the child with the same toilet tissue, and then the child developed chlamydia. I mean, it is possible that that could be a case of rare non-sexual transmission, however, that child still needs to be assessed for sexual abuse, still needs to be tested for other anogenital exams, needs a forensic interview, and needs testing for other sexually transmitted infections. Syphilis is transmitted by sexual contact unless there is evidence of perinatal transmission or clearly documented, but rare non-sexual transmission. HIV, again, transmitted by sexual contact if perinatal or blood transfusion transmission can be ruled out. Anogenital warts, anogenital herpes may be sexually transmitted, but also may not be sexually transmitted, and we will talk more about anogenital warts or HPV and anogenital herpes or HSV later. Molluscum contagiosum in prepubertal children, most likely non-sexually transmitted. In the prepubertal child who's positive for gonorrhea, chlamydia, and trichomonas, we all recognize that there really is significant forensic value to a positive lab result for chlamydia, gonorrhea, or trichomonas in a young child. You should have them return to clinic, collect another specimen for confirmatory testing. Even though the NAT has a built-in confirmatory test, this just is an extra layer of icing on the cake. Treat the infection, have the child return in about three to four weeks for test of cure because we want them back for test of cure, number one, to make sure the infection is gone away, but number two, because we want to make sure that the child is indeed being protected and the person that gave them the sexually transmitted infection no longer is infecting them. We need to report to Child Protective Services and law enforcement, and this child needs to be tested for other sexually transmitted infections, needs to be tested for chlamydia, gonorrhea, trichomonas, regardless of which of those infections they were tested for, needs to be tested for HIV, hepatitis B and C, and syphilis. This is the treatment for chlamydia in a pre-pubertal child. This is the treatment for gonorrhea in a pre-pubertal child. And this is the treatment for trichomonas in a pre-pubertal child. This is the treatment for primary or secondary syphilis treatment. Honestly, if, and honestly, I'll knock on wood when I say this, I've done over 3,000 exams, never had a pre-pubertal child who tested positive for syphilis, but if I did this, I would contact Infectious Disease to discuss treatment with the Infectious Disease Specialist and refer the child on to the Infectious Disease Specialist to make sure the syphilis had cleared. Antigenital warts or herpes may or may not be sexually transmitted. Antigenital condyloma or warts is diagnosed by physical exam, by the visualization of the lesions. It may be sexually transmitted, can also be transmitted perinatally. The incubation period for the HPV virus is really unknown, and it may be like up to five years. Adam states that antigenital warts first discovered in a child at age five or older, the concern for sexual abuse should be higher. But I do know I've had many parents say, oh yeah, when he was born, there was a little bump around his butt, and I didn't think anything of it. And she said, I even mentioned it to the doctor, and the doctor didn't think anything of it. And then the child turns three or four, and they just proliferate in numbers. They multiply, and then they become irritating to the child. And yet, probably the most likely mode of transmission was perinatal. Auto-inoculation can also occur. A child with warts on their hands, touches their genitals or their butts, transmits it in that way, or a caregiver with warts on their hands. In toileting, a young child could transmit the HPV virus. Antigenital herpes, type one or type two, is confirmed by PCR testing or culture. And type two is most common, antigenital, but you can also have type one in the genital or anal area. Antigenital herpes, too, can be sexually transmitted, but it can also be transmitted by auto-inoculation. A child with oral herpes touches their hand to their mouth and touches their genitals or their butts, or a caregiver with oral herpes touches their hand to their mouth and then diapers a child. So you can see with antigenital warts or herpes, it's really important to obtain a very thorough medical history. For warts, you want to know if mom has ever had, if mom has genital or anal warts, has mom ever had abnormal pap smears? Because oftentimes there's no visual warts, but the mother may have had an abnormal pap smear. You want to ask about a history of warts on the hands or on the bodies of other members in the family or a history of them for the child. So you do want to obtain some additional history information. And the same for herpes. You want to know, has this child ever had oral herpes before or anyone in the family with oral herpes? These children with antigenital warts or herpes all need a forensic interview. They need a thorough medical history obtained. They need an antigenital exam. They need testing for other sexually transmitted infections, chlamydia, gonorrhea, trichomonas, HIV, syphilis, hepatitis B and C, and report to Child Protective Services and law enforcement definitely if the child gives any history of sexual abuse, if there's any antigenital trauma, acute or chronic trauma noted on exam, or if the child has another sexually transmitted infection, or certainly for antigenital warts, if the child is above age five and there's no non-sexual explanation for the warts, meaning mom has no abnormal paths, mom doesn't have any history of genital warts, child doesn't have any history of warts on their hands, you would want to report. And with antigenital herpes, more often than not, you are going to report just so that there can be a thorough investigation by Child Protective Services. Here's some examples of antigenital herpes. They're treated with antivirals, SITZBAS for discomfort, and over-the-counter analgesics. You can tell by looking at these lesions, this would hurt. You certainly want to make sure the child's able to urinate, and the SITZBAS can help with that as well. Antigenital warts, and you can see, they look kind of different. They're different look. They don't always look the same. And again, different looks. These children need referred to, well, certainly if they're in the introitus of the genital area, they need a referral to pediatric gynecology for treatment. You can also refer to dermatology or like the photo on the right, on the bottom, that condyloma is extending really to the anal verge. You could refer that child to pediatric surgery because there could also be a concern for internal warts. Then look at these syphilis lesions. They kind of look like warts and herpes in a way, don't they? That's why it's important for any child that you think has genital warts or genital herpes to also test for syphilis because you never want to miss a case of syphilis. Molescum contagiosum can be confused for warts, but if you'll see in the center of that papule, there's an umbilicated center. It kind of dips in, so that's kind of the difference, but it's not unusual for molescum contagiosum to be confused for antigenital condyloma. I just wanted to briefly talk about HIV in pediatric sexual abuse or sexual assault. HIV is the only sexually transmitted infection that in the prepubertal population that we as forensic nurses need to consider prophylaxis for. And this slide just kind of gives a little algorithm of risk assessment. If it's been greater than 72 hours, there's no need to initiate HIV PEP. If it's been less than 72 hours and the perpetrator is known to be HIV positive, then of course HIV PEP is initiated. If the source is the HIV status of the perpetrator is unknown, then you kind of have to look a little closer. And let me show you, this is the risk of HIV transmission per exposure event. And you see with blood transfusions, 95% chance of transmitting HIV. Needle exposure, again, 13 to 45%. Oh, that's perinatal exposure, excuse me. Perinatal exposure in an untreated mother would be 13 to 45%. Needle sharing, 0.67%. And then when we get to unprotected receptive anal intercourse, you'll see that the risk is really quite low, 0.05 to 0.3, but it's not nothing. So it's certainly something we need to consider. And the same for unprotected receptive vaginal intercourse. The risk is 0.01% to 0.03%. Not high, but any risk is a risk. So when you're conducting an HIV risk assessment, you need to look at the sexual act, the perpetrator, and whether or not there is anogenital injury. So is there a history of anogenital contact or genital-genital contact? And without the use of a condom raises risk as well. Is the perpetrator known? Is the perpetrator known to be HIV positive? You know, then you're definitely going to prescribe HIV pep. Is the perpetrator known to engage in male-on-male sex or IV drug use? Then, yes, you should recommend HIV pep. For other known perpetrators, I think it's worthwhile to have a conversation with the parent about whether they really feel that this individual is at risk to be HIV positive. Unknown perpetrators, certainly unknown perpetrators with anogenital injury, yes, HIV pep. And when, in fact, any unknown perpetrator, I would encourage a family to consider initiation of HIV pep when there's been unprotected receptive anal intercourse, unprotected receptive vaginal intercourse, or unprotected insertive vaginal intercourse. HIV pep must be initiated within 72 hours, must be taken for 28 days. These are the initial labs that need to be drawn. You don't need to wait on initiating the HIV pep, giving the medication before the lab results come back. You can give the meds before the lab results come back. And the child needs referred to an HIV specialist. And I should have mentioned, in all acute cases of sexual assault, when we're testing for HIV, syphilis, and hepatitis B, C, those need to be repeated in six weeks, three months, and six months. When a child's on HIV pep, typically they're referred to an HIV specialist, and sometimes the HIV specialist may handle the follow-up lab work. Here is the drug regimen for patients greater than 25 kilograms. And HIV pep is not without side effects. It can cause malaise, nausea, and vomiting. And the child just may not feel that good, usually for a week or two, and then their body gets used to the medication. This is the three-drug regimen for six months or less than 25 kilograms. And they will also need an anti-emetic. And these drugs tend to have more side effects than the drugs that we can give to the older kids. The ADAMS criteria in 2023 also addresses gardnerella vaginalis and bacterial vaginosis. Gardnerella is the most common cause of bacterial vaginosis. Both of these infections are common in sexually active adolescents and adults, but they're uncommon in prepubertal children. However, bacterial vaginosis caused by gardnerella has been found in children thought to be sexually abused and those thought not to be sexually abused. Gardnerella is considered a normal vaginal flora. And it's thought that rather than, even in adults and adolescents, rather than gardnerella vaginalis or bacterial vaginosis being sexually transmitted, it is thought that sexual contact alters the vaginal flora and overgrowth of gardnerella results in vaginosis. These infections, bacterial vaginosis, may increase the risk of infection with other sexually transmitted infections, such as HIV. So bacterial vaginosis caused by gardnerella as an isolated finding in a child. Let's say the child goes to the primary care provider for vaginal discharge and the testing reveals gardnerella vaginalis. So there's an, but all of the other testing the child's tested for chlamydia, gonorrhea, trichomonas, that's negative. It's an isolated finding in this child. This child needs to be screened for sexual abuse, meaning they need to be asked about sexual abuse and inappropriate touching on their body. They need to be tested for other sexually transmitted infections, such as chlamydia, gonorrhea, trichomonas, genital, if they were not previously tested, and HIV, syphilis, hepatitis B. But it is important to realize that gardnerella vaginalis or bacterial vaginosis may be transmitted via non-sexual sources. So if it is an isolated finding in a child, you would not report a concern of sexual abuse to Child Protective Services and or law enforcement. Now, and also as pediatric forensic nurses, we shouldn't be, there's no need to include screening for bacterial vaginosis in our general care of sexually abused children. Well, we talked about a lot of things. If you have any questions, please shoot me an email. There's my email. Well, thank you for joining in this online learning.

Gail Horner

Forensic Nursing Specialist

Pediatric Medical Forensic Examination Essentials

child sexual abuse

medical forensic examinations

anogenital exam techniques

sexually transmitted infections

adverse childhood experiences

chronic stress

forensic evidence collection

prophylaxis for HIV

pediatric medical forensic examination

forensic nurses

child sexual abuse statistics

long-term consequences of abuse

pre-pubertal patients

sexually transmitted infections testing

HIV prophylaxis

Forensic Nurse

Indications for medical forensic examinations

Normal and abnormal findings

Long-term consequences

Neglect

Physical abuse

Sexual abuse