B3. Entry into the Health Care System

Examples of Common Developmentally Appropriate Sexual Behaviors Among Children[4]

(Note these behaviors do not constitute sexual abuse and are distinguished from inappropriate/problem sexual behavior that may raise a suspicion of sexual abuse)[5]

Developmental Stage/Age

Common Sexual Behaviors

Preschool

(Under 4 years old)

· Exploring, touching, and/or rubbing private parts, in public and in private

· Showing private parts to others

· Trying to touch mother’s or other women’s breasts

· Removing clothes and wanting to be naked

· Attempting to see other people when they are naked or undressing

· Asking questions about their own and others’ bodies and bodily functions

· Talking to children their own age about bodily functions such as “poop” and “pee”

Young Children

(4–6 years old)

· Purposefully touching private parts, occasionally in the presence of others

· Attempting to see other people when they are naked or undressing

· Mimicking dating behavior (such as kissing or holding hands)

· Talking about private parts and using “naughty” words, even when they do not understand the meaning

· Exploring private parts with children their own age (such as “playing doctor,” “I’ll show you mine, if you show me yours,” etc)

School-Aged

(7–12 years old)

· Purposefully touching private parts (masturbation), usually in private

· Playing games with children their own age that involve sexual behavior (such as “truth or dare,” “playing family,” or “boyfriend/girlfriend”)

Key Steps in Initial Health Care Assessment/Triage

Step 1: Make children who disclose sexual abuse or are suspected of being sexually abused a priority.

· See children presenting with sexual abuse issues in a timely fashion. To the extent possible, use a private location within the facility to initially assess/triage the child and as a waiting area for the caregiver/family. Inform the child and caregiver what will happen during the initial assessment/triage (e.g., a medical screening will confirm that no emergent conditions exist and help plan for specialty care).

· Be aware that it may be particularly uncomfortable for some children and caregivers to speak about the abuse in general, but especially with members of the opposite sex. To the extent possible, accommodate requests for providers of a specific gender or culture.

· This section focuses mainly on health care providers who interact with children prior to the pediatric examiner’s involvement. However, if there is a pediatric examiner at the facility, seek to involve the examiner as early as possible (e.g., if emergency department staff knows a child victim is being transported to the facility, they may be able to reach out to the examiner at that point or the examiner could meet the patient immediately after triage).

Step 2: Gather minimal facts during the initial assessment/triage.

· The initial assessment/triage of the child should include questions that are limited in scope—the focus is for the health care provider to obtain sufficient information to make a mandatory report and to determine whether the urgency for medical forensic care is acute or non-acute. Questions should only include what is necessary to identify the child’s presenting issues and treatment needs, and the nature and timing of the abuse. It is helpful to know whether other responders/providers are already involved in the case, as they may be able to share pertinent case information that will help limit the questions the health care provider needs to ask. Note further information will be sought from the child and caregiver during the medical history component of medical forensic care, as well as the investigative interview/forensic interview.

· Be familiar with examples of initial assessment/triage questions to ask accompanying caregivers (Floyed et al., 2011; Giardino & Finkel, 2005; Hornor, 2010): When did the sexual abuse last occur? What type of contact happened (e.g., oral to genital, genital to genital, or genital to anal?) Or, if unknown, what has prompted a suspicion of sexual abuse? (Often, there is no knowledge, but a behavioral issue OR a finding that the parent has observed that has raised her/his index of suspicion) Did/does the child have anogenital pain, bleeding, or discharge, or a known genital injury? What access does the perpetrator (if known) have to the presenting child and contact children? Do safety concerns exist? Are there other physical concerns (related or unrelated to the abuse)?

· Note that the person from whom information should be obtained depends somewhat on the presenting situation. In an emergency department setting, health care providers usually direct the question of what brings the child to the hospital to the accompanying adult.However, depending upon developmental level and communication skills, the child may be able to answer basic questions (What brings you in today? Does anything hurt?). In a primary care setting, the caregiver or the child may verbalize the chief complaint.Although providers should not pursue obtaining a detailed abuse history from the child, it is possible that a child will make a disclosure spontaneously or with little prompting. In this case, the child needs to know that it is acceptable to talk with trusted adults about what happened. Such disclosure should be documented verbatim. To the extent feasible, separate the child from the caregiver when obtaining this information. Separation is particularly important if the caregiver is a suspected perpetrator, is in collusion with the perpetrator, or is otherwise abusive to the child.[6]

Step 3: Ensure that, when prepubescent child sexual abuse is disclosed or suspected, a mandatory report is made as per jurisdictional and facility policies. (See A5a. Reporting )

· Make the report after basic facts about the nature and circumstances of the abuse are gathered.

· Do not delay health care due to confusion about which jurisdiction should receive the report, if there is a problem communicating with legal authorities about the report, or if the jurisdiction in which the abuse occurred differs from the one in which the health care facility is located.

Step 4: If immediate safety concerns are identified, promptly communicate the urgency of the concern to the appropriate law enforcement or child protective service agency, as per jurisdictional and facility policy.

· If there is concern about a safety threat posed by a person accompanying the child, take steps to protect the child and the facility staff from that individual. In addition to immediate outreach to the appropriate law enforcement and child protective service agency, follow facility policy on response to this and other types of threatening situations. It is important that facilities and providers have the ability to create a safety plan, including admission when necessary (if the facility has inpatient capacity).

Step 5: Provide a medical screening exam (as per EMTALA requirements) to include vital signs and evaluation by a qualified medical provider for acute injury or pain and subsequently treat, as needed, to stabilize.

· Be aware that emergent treatment needs always supersede forensic evidence preservation.

· If the abuse occurred in the recent past (see below), strive to preserve potential evidence on the child’s body for later collection during the medical forensic examination. To that end, do not remove the child’s clothing or have him/her wash or bathe. If a child must eat or drink, oral swabs can be taken—consult with a pediatric examiner as needed to ensure that swabs are collected properly. If the child needs to urinate, a sample (dirty catch) should be obtained as it may be needed for STD or toxicology testing. Soiled diapers or underwear should be maintained as part of the collection process. Procedures should be in place to facilitate the passing along of any material or samples collected to the pediatric examiner or law enforcement representative, in a manner that maintains the chain of custody of forensic evidence. (See A5e. Evidence Integrity and B8. Evidence Collection )

Step 6: Recognize that medical forensic care falls into two categories: acute or non-acute. All prepubescent children who disclose sexual abuse or are suspected of being sexually abused require medical forensic care due to health consequences associated with sexual abuse (Day & Pierce-Weeks, 2013). Follow jurisdictional and facility policies for determining the urgency of care.

· Generally, an acute examination (emergent or urgent care[7]) should be conducted for a child who has disclosed sexual abuse or is suspected of being sexually abused if:

o The sexual abuse may have occurred recently (as per the jurisdictional prescribed time frame for acute medical forensic care) and there is a possibility of forensic specimens on the child’s body from the contact (see A5d. Timing of Evidence Collection );

o There are symptoms of injury, anogenital or other (e.g., bleeding, bruising, abrasions, and lacerations);

o There are symptoms of STDs (e.g., discharge from genitalia, pain, or sores), including HIV;

o The situation (e.g., the child is unconscious) or the child’s cognition (e.g., pre-verbal infant/toddler) prevents an understanding of the time frame since the sexual abuse or of the severity of injuries;

o The child was abducted and sexual abuse is suspected;

o There are imminent safety risks to the child and it is unclear where she/he will reside in the future;

o There is a concern that the family will not return the child for non-acute care on another day;

o The child is experiencing significant behavioral or emotional problems and/or a need exists for evaluation for possible suicidal or homicidal ideation; and/or

o The child or caregiver has pressing concerns that acute care can address (e.g., about STDs).

· Children should be referred for a non-acute examination (non-urgent care) if the sexual abuse is suspected to have occurred beyond the jurisdictional time frame for forensic sample collection and there is no indication for the need for immediate medical attention as described above. Although forensic samples are not collected in these instances, these children do require a thorough medical forensic evaluation consisting of a medical history and examination. Because child sexual abuse reports are often delayed, a non-acute examination rather than an acute exam is appropriate in many cases.

· Recognize that the disclosure of child sexual abuse is often a crisis to the child and family, even if it does not require emergency medical attention (Christian, 2011; Leder, 2012). In such instances, it may be beneficial to conduct an examination acutely to reassure the child and family (Christian, 2011), as well as to offer crisis intervention and support, and link the child and family to advocacy and mental health services.

Step 7: Once the urgency of medical care is determined, arrange the appropriate examination.

· Follow the protocol for arranging medical forensic care, as per jurisdictional and facility policy.

o The multidisciplinary response team (or responding entities) should work in conjunction with local and regional health care systems and pediatric examiners to ensure that primary care providers and hospital emergency departments in the team’s service area have a consistent protocol to arrange medical forensic care. The protocol should identify acceptable time frames for acute and non-acute care, once the urgency of care is established and the patient is stabilized.

o Acute and non-acute examinations may be conducted in designated health care facilities in a jurisdiction or region. Some exam facilities perform acute and nonacute examinations; others perform only one type. Some have time restrictions (e.g., many children’s advocacy centers’ medical clinics are open only during standard business hours). (See A4b. Facilities )

o When arranging medical forensic care, health care providers need to be informed of: available medical forensic exam resources in the community; which location and time frame is best for different exam types and pediatric populations; transfer options and procedures if a child must be sent to another facility for acute medical forensic care (they should not send a child who requires acute medical forensic care home without a medical forensic examination); and options and procedures for arranging non-acute examinations.

o If at all possible, develop mechanisms to provide initial responders with access to pediatric examiner consultants whom they can call for guidance in directing children to the right provider, facility, and services.

o Recognize that transportation for non-acute care may be an issue for caregivers. The multidisciplinary response team (or responding entities) should offer accessible transportation at no cost for children and caregivers to ensure non-acute care occurs in a timely manner.

Step 8: Alert exam facilities according to jurisdictional and facility policies.

· For acute examinations, alert the appropriate exam facility that an immediate need exists for a pediatric examiner to provide medical forensic care. If the examination will take place at the initial health care facility to which the child presented and examiners are not based at the site or need to be dispatched, they should be contacted as per facility policy.[8] Examiners are often required to arrive at an exam site within a certain period of time (e.g., one hour) after being dispatched. If the child is going to be transferred to another facility for the acute care, that facility should be alerted regarding the patient’s pending arrival and then established policies should be followed for the transfer. Communication between the health care provider performing the initial assessment and the specialty care team at the transfer site may assist in the child’s plan of care and expedite the transfer. (See A4b. Facilities )

· Note that in circumstances in which patients are seriously injured, pediatric examiners must be prepared to work alongside other health care providers who are stabilizing and treating the patients. In such cases, examiners should be prepared to perform examinations in settings such as a health care facility’s emergency department, an operating room, a recovery room, or an intensive care unit.

· For a non-acute examination, providers at the initial responding facility should follow jurisdictional policy for outreach to the exam facility to ensure that specialty care is available and to schedule an appointment for the child.

Step 9: Alert victim advocates to the need for their services (where available)

· Determine if/which victim advocacy services are available to children and/or family members before, during, and after the medical forensic examination to offer crisis intervention, support, information, safety planning, counseling, and advocacy services.

o The multidisciplinary response team should work with local and regional victim advocacy programs serving prepubescent child sexual abuse victims to ensure that children and their caregivers have access to advocates during the exam process and that informed consent is sought from the child and caregivers when involving advocates. In conjunction with the advocacy program, the team should also develop procedures for health care providers to activate an advocate in these cases to provide medical accompaniment. (See A3. Coordinated Team Approach and B1. Consent for Care )

· Follow established procedures for activating an advocate, as per jurisdictional and agency/facility policies.