B7. Examination

These recommendations are for pediatric examiners regarding conducting the examination.

Keep the focus of the examination on the entire child. The medical forensic examination in a prepubescent child sexual abuse case includes a physical examination augmented by an anogenital examination (MD Child Abuse Medical Professionals Network [CHAMP], 2008). There are many reasons to perform such an examination, the most important of which is to medically evaluate the child’s health (MD CHAMP, 2008). Focus on a full review of systems before moving to the anogenital examination. Besides being more child-focused, victim-centered, and trauma-informed (see A1. Principles of Care), this approach allows examiners to assess for all types of abuse and neglect, not just sexual abuse.

Recognize that medical components of the examination cannot be separated from evidentiary components. In acute cases, pediatric examiners must be prepared to incorporate forensic sample collection into the physical and anogenital examination as it proceeds. (See B8. Evidence Collection) In both acute and nonacute cases, exam findings should be documented—in writing, on body maps and diagrams, and through photography, as per jurisdictional and facility policies. Documentation serves both medical and evidentiary purposes. (See B4. Written Documentation and B6. Photo-Documentation)

Explain the overall examination to the child and caregiver prior to the examination, as well as specific procedures during the examination. Seek consent and assent as appropriate. (See B1. Consent for Care) Convey the following (drawn from Sanford Health Dakota Children’s Advocacy Center, 2014):

• The examination is a thorough physical evaluation, similar to an annual pediatric well-check visit.
• The health care provider evaluating the child is someone who has expertise with children who have been sexually abused.
• The examination is typically painless. It will include an examination of the genital and anal area. Generally speaking, a speculum will not be used. Sedation or anesthesia is necessary only in rare situations in which there are concerns of significant anogenital bleeding or injury, a mass, or a foreign body.
• Photographic images will be taken to document the physical findings and ensure the accuracy of the interpretation of these findings. The images will be securely stored at the health care facility and access to them is controlled. (See B6. Photo-Documentation)
• The child is in control of what happens during the examination. The health care provider will explain what is happening during the different steps of the examination. If the child expresses an interest, exam equipment can be demonstrated. Questions are encouraged and breaks can be taken whenever needed.

In most instances, when examiners establish rapport with children, explain exam procedures to them, and welcome their questions, children are able to complete the examination without difficulty.

Modify the examination to address the specific needs and concerns of children. (See A1. Principles of Care and A2. Adapting Care for Each Child) For example:

 

Accommodate mobility and cognitive impairments and communication needs.^[1]

• Accommodate requests for examiners of specific genders to the extent possible—cultural beliefs may preclude a member of the opposite sex from being present when a child disrobes.
• Be aware that cultural beliefs might affect whether and how certain forensic evidence is collected and if/how photo-documentation is done. (See B6. Photo-Documentation) If children or caregivers are hesitant or opposed to a specific procedure for this reason, it can be useful to explore whether an alternate method may make the procedure acceptable while respecting their cultural practices. In general, do not interfere with cultural practices that promote healing, even if the practice may compromise forensic evidence collection.
• If certain items that are considered forensic evidence have cultural significance (e.g., sacred ceremonial garments and jewelry, and moccasins of a Native person), use of alternative collection techniques, such as swabbing the clothing, should be considered rather than taking the items as evidence.

Clarify who can be in the exam room beyond the child, examiner, and chaperone. A chaperone is necessary during the medical forensic examination as a safeguard for children, due to their vulnerability to abuse. The chaperone may be a caregiver, a health care provider other than the examiner, or another supportive person not suspected of involvement in the abuse.^[2] Beyond these individuals, it is generally good practice to limit the number of persons in the exam room, to protect patient privacy and simply because the room often cannot accommodate more than a few individuals. However, depending on preferences of the child, case facts, jurisdictional policies, healing practices of the family, etc., it may be appropriate for additional individuals to be present in the room: assisting medical personnel,^[3] a victim advocate, other supportive persons (e.g., a religious/spiritual support person), a provider to assist with communication (e.g., an interpreter), and/or a personal care attendant for a child with a disability.^[4] Law enforcement or child protective service representatives should not be present during the examination.

It is important to give children the choice of whether a caregiver is present during the examination, if they are developmentally able to make an informed choice. Yet, examiners must understand that it may be difficult to impossible for children to make such a decision without being influenced by the perceived consequences (e.g., my mom will be mad if she has to leave the room). Prior to the examination, e xaminers should assess the relationship between the child and caregiver (if the caregiver is supportive of and able to comfort the child during the examination), explain the options to the child, and assess if the caregiver’s presence could be potentially disruptive during the examination. Separately from the child, it is helpful if examiners stress to caregivers that the examination is noninvasive and generally not traumatizing for children when done in a child-focused, victim-centered, and trauma-informed way and that it will not be forced on them.

Examiners can also educate caregivers about their critical role in their child’s healing and suggest and model ways to support the child during the examination. Generally, most children find it reassuring to have a supportive caregiver or other support person present during the examination. However, a caregiver who is suspected of being the perpetrator, is in collusion with the perpetrator, or is otherwise abusive to the child should not be present. In situations where a caregiver is too emotionally distressed to support the child or does not believe the child’s account of sexual abuse, it may prudent to limit her/his participation.^[5]

Take measures to protect patient privacy when others are present during the examination. In addition to documenting their presence in the child’s record and appropriately draping, position additional persons appropriately and explain their roles to the child. Those providing support should understand their role is to talk to and distract the child during the examination (WA, 2012). They should not actively participate.

Document verbatim spontaneous statements made by the child in the course of the examination, if it is related to the health and wellbeing of the child, child abuse and neglect, or other purpose deemed important by the examiner.^[6]

Conduct a head-to-toe examination, as summarized below (Day & Pierce-Weeks, 2013). The examination should proceed in a way that affords as much dignity, privacy, and comfort to the child as possible. (See A1. Principles of Care) Limit exposure of the body to the area being examined (e.g., when observing the breast, only expose that particular area). Note that an alternate light source (ALS), if available, can aid in examining the body, hair, and clothing.^[7] (See A4c. Equipment and Supplies)

 

Head-to-Toe Exam Steps

Note that this list is a detailed summary of common steps; jurisdictions may differ as to the specifics of steps.

Observations	Other
Note the child’s general appearance, demeanor, and developmental stage. (See Appendix 1. Tanner Stages of Sexual Maturation)	Take vital signs, height, and weight. Also obtain head circumference for children under 3 years of age.
Inspect the head and scalp. Observe for areas of missing hair and evidence of bruising/petechiae on the scalp.	Palpate the scalp for areas of tenderness. Gentle palpation may reveal tenderness and swelling, suggestive of hematoma. Hair loss due to hair pulling during the abuse may cause loose hair to be collected in the examiner’s gloved hands or petechiae at the surface of the scalp. Gentle palpation of jaw margins and orbital margins may reveal tenderness, indicating bruising not yet visible.
Inspect the eyes. Observe for areas of bruising around the eyes (may be subtle). Look for the presence of conjunctival petechiae or hemorrhage.
Inspect the external and internal ears. Do not forget the area behind the ears, for evidence of shadow bruising or battle signs (which may be a sign that a skull fracture exists). Bleeding or leakage of cerebrospinal fluid (CSF) from the ear may also indicate skull fractures.
Inspect the nose and mouth. Look in the nose for signs of bleeding or leakage of CSF, or areas of bruising on the outside of the nose. The mouth should be inspected, including the lips, gums, and tongue, checking for injury and the buccal mucosa. Petechiae on the hard/soft palate may indicate oral penetration or strangulation. Check area of the frenulum for tearing injuries and observe for broken teeth.	Collect oral swabs, as indicated.
Inspect all surfaces of the child’s neck for injury. Injuries observed on the neck can indicate a possible strangulation event warranting further questions by the provider.	Palpate the neck for subcutaneous emphysema and note any ligature marks. Any of these signs may indicate a strangulation event has occurred. Abrasions seen at the neck in cases of strangulation may be caused by the child when trying to protect him/herself from strangulation. Petechiae or red bruising from bites or sucking should be noted and swabbed for saliva before being touched.
Assess the child’s hands, inspecting all sides for injury. Observe general appearance. Observe wrists for signs of ligature marks.	Collect trace evidence from fingernails and along the cuticles, as appropriate.
Inspect the child’s forearms for injuries, appropriate circulation, sensation, and motion. Note any injuries or intravenous puncture sites.	Palpate for tenderness.
Inspect the inner surfaces of the child’s upper arms and axilla for signs of injury, appropriate circulation, sensation, and motion.	Children who have been restrained by hands may have “fingertip” bruising on their arms.
The child’s breasts and trunk should be examined. Subtle or obvious injury may be seen in a variety of places on the trunk. Breasts are frequently a target of abuse in female patients, including sucking and bite marks.	Swab areas for saliva if indicated. Auscultate the lungs.
Observe the child’s back; this can be accomplished by rolling the child over to complete the assessment, or by having the child stand up at the exam’s completion and doing a final observation of the back.	Observe for injury and bruising. Be sure to palpate for areas of tenderness.
Complete the abdominal examination, including inspection, auscultation, and palpation to exclude any internal trauma.	If body fluid or saliva is suspected to be present, swab for evidence. Change gloves prior to palpation to avoid examiner contamination (skin-on-skin DNA).
Examine the anterior and posterior aspects of the legs, paying special attention to the inner thighs for injury. Observe for injury and foreign materials. Assess for tenderness. Assess the feet and ankles for similar injury, foreign materials, and tenderness, including the soles of the feet.	Collect foreign materials, if present. Palpate for tenderness and limited range of motion.
Inspection of the posterior aspects of the legs may be easier to achieve with the child standing or sitting on the caregiver’s lap. Alternatively, the child may be examined in a supine position and asked to lift each leg in turn and then rolled slightly to inspect each buttock.	Any biological evidence should be collected with moistened swabs (for semen, saliva, and blood) or gloved hands (for hair, fibers, grass, and soil).
Obvious physical deformities should be noted. Piercings and other markings should be noted only if their presence is related to the crime (see “other” column).	Notation of tattoos is generally unnecessary unless the presence of the tattoo is related to the crime itself (e.g., the perpetrator tattooed the victim before/at the time of the crime, as may occur with trafficking victims).

Conduct the anogenital examination. The anogenital examination focuses on the external genitalia of prepubescent boys and the labia and contents of the vestibule of prepubescent girls. The presence of a chaperone for the child is particularly important during this part of the examination. A speculum examination of the vagina is not indicated for a prepubescent girl with an unestrogenized hymen unless there are concerns of bleeding, a mass, or a foreign body. If an intra-vaginal examination is required, sedation or anesthesia must be used. In this case, consult as needed with appropriate pediatric specialists.

A digital camera or colposcope and magnifying glass/visor can aid in visualizing anogenital structure detail.^[8] As noted earlier, an ALS can aid in examining patients’ bodies, hair, and clothing. (See A4c. Equipment and Supplies)

Use specific exam positions and techniques to facilitate the examination of genitalia in prepubescent children. Note that modifications may be needed for children with mobility impairments, as indicated by the medical history.

 

Exam Positions and Techniques^[9]

 

NOTE:  For full size illustration, see Appendix 2.

 

Examination Positions and Techniques[10]
Position/ Technique	Description
Supine frog-leg position	The child lies on the exam table or lap of a caregiver, with feet close together and knees loosely apart. Allows for visualization of the labia, and ease of use with labial separation and traction techniques. Allows for view of vulva, hymen, and vestibule. Abnormalities should be confirmed in prone knee-chest position (Kellogg, 2011).
Supine knee-chest position	The child lies on the exam table or lap of a caregiver, with feet and knees together holding knees to chest (may need assistance). Allows for visualization of the anus and surrounding tissues.
Prone knee-chest position	The child is on exam table in a prone position, with head and torso flush with the table, knees separated and down on the exam table, and buttocks raised. Allows for visualization of the anus, surrounding tissues, and rectal cavity during relaxation.With use of labial separation and traction, allows for assessment and confirmation of hymenal findings visualized while the child was in supine frog-leg.
Labial separation technique	With the child in a supine frog-leg position, gently separate the child’s labia with gloved hands. Allows for visualization of the genital structures.
Labial traction technique	With the child in a supine frog-leg position, gently hold the child’s labia majora bilaterally between thumb and forefingers with gloved hands, pulling out toward the examiner and down toward the anus of the child. This technique allows visualization of the genital structures including the hymen, vaginal opening, and posterior fourchette areas. Care should be taken to avoid injury of the posterior fourchette before, during, and after the examination.
Floating hymen technique	If the hymeneal tissue appears folded on itself or adhered together, the use of saline to moisten the hymen’s edges may improve visualization, allowing a more complete assessment. This technique can be performed with the child in prone knee-chest position with gluteal lift (Adams et al., 2015; Kellogg, 2011).

For children who are anxious about the anogenital examination, consider if there may be modifications that could ease their anxiety. For example, if the child is hesitant to remove her/his underwear or clothing, ask the child if the caregiver could help. In acute cases, examiners can give the caregiver gloves to use and provide instruction to preserve forensic evidence during removal. It might be reassuring for an anxious child to be examined on a caregiver’s lap rather than on the exam table (see above positions). If children decline the anogenital examination altogether, they may still allow the physical examination and swabs of the head, neck, chest and abdomen. They may allow underpants to be collected, especially if new underpants are provided. ^[11]

Genital Examination of Prepubescent Girls

In girls, assess the following external genital structures for injury or disease process:
· Mons pubis · Labia majora and minora · Clitoral hood and clitoris	· Urethra and periurethral tissues · Perineum · Posterior fourchette	· Fossa navicularis · Hymen · Vaginal vestibule

Female Genital Anatomy[12]

 

NOTE:  For full size illustration, see Appendix 3.

Document the genital structure assessment and findings using the clock face analogy. See illustration (Image courtesy of the New York State Department of Health). Some examiners assign the 12 o’clock position to the urethra, causing the clock position to change when the child’s position changes. Others have the clock positions remain the same, and always document the position of the child when describing a finding. Each examiner should choose the method that best suits their practice and adhere to that method for each examination. The examiner superimposes the clock face and uses the appropriate time to document what is observed. Note the type of injury; size, if possible; structure upon which the injury is observed; and color of injury; discharge; foreign bodies; and/or blood.

 

Note the hymen of prepubescent girls is sensitive and will cause the child pain if touched. Techniques used in postpubertal girls for hymenal assessment, such as the cotton-tipped swab to examine edges of the hymen or the urethral (Foley) balloon catheter technique, should not be used with prepubescent girls.

Genital Examination of Boys

Include the following structures and tissues in the genital examination of boys, checking for signs of injury or disease process (see below for illustration):

· Prepuce of the glans · Glans penis and frenulum · Urethral meatus · Penile shaft

· Scrotum · Testes · Inguinal region · Perineum

Male Genital Anatomy[13]

 

NOTE:  For full size illustration, see Appendix 3.

Anal Examination of Girls and Boys

Utilize either the supine or prone knee-chest positions to examine the anus of children. In either position, apply gentle traction to part the buttock cheeks. Inspect the following tissues and structures during the anal examination, looking for signs of injury or disease process:

· Perianal area, paying particular attention to the perianal folds · Anal verge/margin

· Anorectal canal · Anus · Gluteal cleft

A digital examination should only be performed where laxity of the sphincter is observed.

Anoscopy is not routinely used, unless there is concern of bleeding, obvious trauma, and/or a mass or foreign body. If there are such concerns, anoscopy should be done under sedation or anesthesia and performed by a qualified health care provider.

 

Interpretation of Exam Findings

Recognize that it is normal to have normal physical findings. As discussed in the beginning of this chapter, most children who have experienced sexual abuse have normal examinations. Sexual abuse may leave no permanent scars or marks or, if a disclosure was delayed, healing may have occurred (Jenny, Crawford-Jakubiak, & Committee on Child Abuse and Neglect, 2013). When examination findings are normal, these findings neither confirm nor rule out abuse. Examiners should note this fact in the child’s medical record as well as explain it to caregivers, while reassuring them the child is healthy (Jenny, Crawford-Jakubiak, & Committee on Child Abuse and Neglect, 2013).

Those who review the child’s medical record for investigative purposes also need to understand: why discrepancies may exist between a child’s perception and description of the event, due to developmental level, and what actually occurred; the presence or absence of exam findings; and what symptoms might be expected with various types of anogenital contact (Kaplan et al., 2011). For example, any contact against an unestrogenized hymen when the labia majora is penetrated could result in the child reporting “something hurt when it went inside.”

 

Educate pediatric examiners on normal variants and conditions erroneously associated with sexual abuse (Adams et al., 2015). A wide range of normal findings can be expected during the medical forensic examination of prepubescent children (Day & Pierce-Weeks, 2013). At a minimum, examiners should understand anatomical variations and disease processes commonly mistaken for sexual abuse—see below for key examples (Day & Pierce-Weeks, 2013). The information gathered during the child’s medical history is critical in differentiating between an injury from sexual abuse or variant.

It is critical that examiners are objective, know the limitations of clinical observations, and incorporate differential diagnosis to formulate unbiased diagnosis (Kaplan et al., 2011). Use of clinical peer review can help strengthen their skills to not overcall a normal variant finding as consistent with sexual abuse (Adams et al., 2015). (See A4a. Pediatric Examiners)

Differential Diagnosis of Genital Findings[14] (not inclusive)
Anatomical Variations & Disease Processes	Common Findings Mistaken for Sexual Abuse in Prepubescent Children
Labial agglutination or adhesion	The result of adherence (fusion) of the adjacent, outermost, mucosal surfaces of the posterior portion vestibular walls, which may occur at any point along the length of the vestibule, although it most commonly occurs posteriorly (inferiorly). A common finding in infants and young children. Unusual to appear for the first time after 6 to 7 years of age. May be related to chronic irritation.
Lichen sclerosis	A chronic, atrophic condition that creates patchy, white skin that is thinner than normal. Lichen sclerosis may affect skin on any part of the body, but most often involves skin of the vulva, foreskin of the penis, or skin around the anus. There is often associated itching, which can result in areas of bleeding and irritation.
Urethral prolapse	A condition in which the urethra protrudes through the external meatus. It may have a swollen, reddened appearance.
Streptococcus infection	Group A streptococci are gram-positive bacteria that produce beta-hemolysis and appear usually as a chain of two or more bacteria and have molecules on their surface known as Lancefield group A antigens. It can cause vulvitis in prepubescent girls; the peri-vaginal mucosa may be swollen, erythematous, and there may be bleeding and a discharge (Hudson et al., 2011).
Staphylococcus infection	Staphylococcal infections are caused by Staphylococcus bacteria, a bacteria commonly found on the skin or in the nose of even healthy individuals. It can cause vulvitis, vulvovaginitis, and vaginitis in prepubescent girls and may be accompanied by discharge (Hudson et al., 2011).
Straddle injury	Injury that can occur in the urogenital area from a fall, where the child “straddles” an object. It can be caused by blunt force trauma, which compresses urogenital soft tissues against the bony margins of the pelvic outlet, or less commonly, when a sharp object directly and forcefully penetrates the perineum, vagina, or anorectal opening. A common complaint is blood in underwear or on the perineum. Straddle injuries may result in abrasions, bruising, or hematoma of the labia majora, mons pubis, external urethra, perineal body, and buttock. Lacerations may occur if a child falls onto object with a hard edge. Penetrating injuries can cause profuse bleeding and pain. Straddle injuries are usually unilateral in presentation. Note that hymen injury is rare in accidental trauma. Male straddle injuries involve the scrotum.
Failure of midline fusion	Also known as perineal groove, congenital finding of the mucosal surface midline between fossa navicularis and anus on perineum. It is distinguished from trauma because it does not change, and resolves at puberty (Jenny, 2011).
Genital irritation/erythema	Difficult to differentiate erythema of nonabusive origin from erythema of sexually abusive origin. Most common causes of genital redness are poor hygiene and contact dermatitis. Increase vascularity in mucosa of vestibule in prepubertal girls that may appear erythematous (See Frasier (2011) for more details).