Physical Examination of Patients with Suspected Sexual Abuse

1. Physical Examinationof Patients with SuspectedSexual Abuse P. Patrick Mularoni M.D.

2. Medical Complaints • Genital, Urethral, or Anal Trauma • Bleeding or Discharge • Dysuria • Abdominal Pain • Headaches • Constipation or Encopresis • Foreign Bodies in the Vagina or Anus • Pregnancy

3. Behavioral Indicators • Temper Tantrums • Sleep Disturbance • Phobias • Self-Injury • Substance abuse • School problems

4. Who Should Be Examined in the E.D. ? • Individuals who report sexual abuse that has occurred within the last 72 hours should have a History and Physical Exam performed as expeditiously as possible • Those individuals with a remote history of abuse should be examined after a disclosure interview is undertaken

5. Preparing for Examination • Patients should be triaged and placed in an appropriate examination room • The Social Worker, Child Life Specialist, and trained Nursing staff should be involved • History may be obtained from the adult who is bringing the child to the Emergency Department in a separate location • While the parent interview is occurring, the patient can become familiar with the Child Life Specialist and the exam room/ equipment

6. Preparation Child Life Specialists use play and actual medical equipment to: • Address concerns • Clarify misconceptions Communicate expectations • Develop trust • Offer coping techniques • Provide familiarity of equipment and environment • Reduce anxiety • Offer choices for feelings of control • Communicates pertinent information to the provider

7. Focusing Techniques/Distraction • “Bubbles • “Viewmaster” • “I Spy” books • “Gameboy” • Headphones • Talking with patient

8. Initiation of Exam • The patient is introduced to the examiner and a brief history is taken from the child - use the patients terms for body parts (privates, girl parts, pee, etc.) - the patient should be reassured that this is a “check up” - use an unhurried approach and allow the pt. to feel “in control”

9. Examination • Start with a familiar head to toe examination - noting: signs of puberty signs of physical trauma adenopathy pharyngitis

10. Examination • Perform genital exam as the next step in a head to toe evaluation - emphasize that you are “taking a look” - point out to the pt. that the colposcope (otoscope) is not touching the pt.

11. Supine Frog Leg

12. Supine Separation Technique

13. Supine Separation Technique • In the supine separation technique, the labia are separated with the tips of the fingers in a lateral and downward movement • The vestibule and Hymen should be exposed

14. Supine Traction Technique

15. Supine Traction Technique • The Examiner grasps the Labia Majora with the thumb and index finger and gently pulls outward and slightly upward • This technique helps the examiner visualize the edge of the hymen more easily

16. Prone Knee Chest

17. Knee-Chest Position • The child rests her head on her folded forearms • The examiner presses a thumb outward on the leading edge of the gluteus maximus

18. Supine Knee Chest

19. Cultures • Pt should be shown the soft cotton tip of the swab • A decision of whether cultures should be obtained should be made and discussed with nursing staff prior to the exaimner entering the room

20. Closing • If the exam is normal be sure to tell the patient that they have a normal exam • If there are findings, reassure the patient that these areas will heal quickly • Patients can also be reassured that when healed, friends and even doctors will not be able to see what has happened

21. Adolescent Female Exam • Adolescent patients should be approached in the same way as prepubertal patients. • The exam and equipment should be explained prior to the examination beginning • Patients should be given reassurance and a sense of control

22. Examination • There is debate as to whether a speculum should be used in all examinations • Presently endocervical cultures for N. gonorrhea and C. trachomatis are the “gold standard” • PCR and LCR studies for ghonorrea and chlamydia testing are ongoing

23. The Rape Kit • All clothing should be individually bagged in a paper bag (not sealed plastic) • Underwear should be placed in the bag provided • If there are visible blood or semen stains moisten one of the enclosed gauze pads and remove the stain. Allow the pad to air dry and place it in one of the plastic bags provided

24. Rape Kit Vaginal or Cervical contact • Swab the Vagina to get as much fluid as possible and wipe cotton swabs across the slides marked VAGINAL SMEARS • Allow swabs to air dry and place them in the envelope marked SWABS • Each envelope and container will be marked with the victims name and what type specimen is contained

25. Rape Kit Anal or Rectal Contact • Moisten two cotton tipped swabs and collect any secretions fro the buttocks and perineal region • Swab the rectal area with 2 cotton tipped applicators and place each in an envelope • Use one of the swabs from the rectum and create a smear on one of the slides provided

26. Rape Kit Oral Contact • Use 2 swabs to swab the oral mucosa • Create a smear with the first applicator • Take the second smear and place it into an envelope marked SWABS

27. Rape Kit DNA Buccal Swabs • Use 2 swabs and rub vigorously along the buccal mucosa and place both applicators in an Envelope marked SWABS

28. Rape Kit Secretions, Stains, or Forensic Materials on the Body • Get a cotton tipped applicator wet and soak against a suspicious bite mark or stain • Allow the applicator to air dry and place the swabs in the Questioned Materials envelope • If there is dried material, scrape the “crusty” material into the plastic material container in the Questioned Materials envelope

29. Rape Kit If history indicates that the assailant was scratched sufficiently by the victim • Collect and visible tissue or blood stains with tweezers and place them in the plastic container in the Questioned Materials envelope • Clip fingernails and place in a piece of paper with a pharmaceutical fold and place in the Questioned Material envelope

30. Rape Kit Hair Samples (Reference) • Pluck or comb out 25 random hairs from the victims head • Use a fine tooth comb to obtain 25 random pubic hairs

31. Rape Kit • If there is matted pubic hair or hair with possible human materials on them then clip those hairs and Place in the Pubic Combings envelope

32. Rape Kit • When you are finished collecting the specimens you are to seal the Sexual Assault Evidence Kit with the orange sticker inside and sign the sticker. • You will also need to fill out the form on the front of the envelope and assure that the nurse that you are giving the evidence to has done the same

33. Documentation • At Hughes Spaulding there is a separate 49 form which needs to be filled out * ONLY UPPER LEVEL RESIDENTS CAN DO A “49” EXAM !!! • At Egelston there is a sexual abuse template that you should look at prior to going into the room (it has many questions that you may not think to ask)

34. Disposition • There should be a Social Work and DFACS referral for all patients with and Alleged Sexual Assault (ASA) • The social worker or DFACS will arrange for follow up which may include a home visit and a forensic interview