DEPARTMENT OF PEDIATRICS

NATIONAL NAVAL MEDICAL CENTER

Standard Operating Procedures

Checklist for Suspected Child Sexual Abuse

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Medical Evaluation

1. History: Take careful notes, document all pertinent information and who said it. Use verbatim quotes. Have someone takes notes for you if possible.

A) With child and family present, go over how the appointment will proceed, past medical history, review of systems, family history, social history.

B) Interview the parents or guardians first, separately from the child. Inquire about allegations, concerning behavioral or physical complaints1 what they know about what happened. Ask about the child's interests, pets, siblings, school, who else they know by the same name, etc.

C) Interview the child without the parent's or guardian present. Introduce yourself as a pediatrician. Explain what a pediatrician does including diagnosing and treating problems both physical and emotional. Make sure the child understands your role and that it is important to tell only the truth to a doctor who is trying to help them. (Medical hearsay exemption). See handout on interview techniques for details, but you should build rapport, determine child's developmental level, communication skills, knowledge of truth/lie and pretend/real, body parts, routine safety issues. Then get into allegations with open ended questions. Never ask leading questions or put words in the child's mouth. Gear questions to the developmental level of the child. Document everything the child says accurately, verbatim if possible.

2.  Physical examination:

A) Gown and sheet--respect their privacy, which may have been violated previously. Ask who they want in the room.

B)  Complete head to toe exam.

C) Colposcopic genital exam, with photos. Tungsten film, Ektachrome 160T, EPT 135-36 (adolescent nurse has some in the clinic and med photo stocks it as well). Use light blue filter on colposcope, all other settings are already done. Take several views of each area with different magnifications. Hand deliver film to med photo, use chain of custody paperwork from med photo. Supine and knee chest positions, separation and traction. May need saline or Q-tips to gently move tissues around.

D) Document exam with words and drawings. If you didn't write it down, you didn't exam it. (Example: The examination was performed in the frog4eg supine and knee chest positions using a photocolposcope through which photographic slides were taken. The genitalia were that of an anatomically normal, Tanner I female. The labia majora, labia minora, and clitoris were unremarkable. The urethra and pen-urethral structures were also normal. Examination of the hymen revealed a crescentic nonestrogenized appearance. The hymenal rim was smooth, translucent, and symmetrical. The hymenal diameter measured 5-6 mm with traction in the frog leg supine position. There were no transections, notched, mounds, or scarring noted on the hymen. The fossa navicularis and posterior fourchette showed no evidence of scarring or trauma. The anal examination revealed normal tone and rugal folds, without scarring, fissures, tags, or asymmetry.)

2.  Laboratory tests and sexual assault kits:

A) Sexual assault kits are obtained through the emergency room or NCIS/CID/OSI. Follow instructions exactly and keep accurate chain of custody documentation. These are usually only done if the alleged assault occurred within 72 hours. Remember to air dry the samples before putting them in the envelopes provided. These kits are not always processed immediately so obtain a second set of cultures and serology to send to our lab for patient care purposes.

B) Laboratory studies:

TABLE 4. Screening for Sexually Transmitted Diseases

Following Sexual Abuse/Assault

Indications

Initial screening at the time of acute sexual assault in adolescents, in

high-risk sexually active patients, or when follow-up is unlikely

· Repeat screening approximately 2 weeks after acute sexual assault in all patients screened initially

· Initial screening approximately 2 weeks after acute sexual assault in low-risk prepubettal patients

· In sexually abused females who have vaginal discharge or a history of vaginal discharge

· In sexually abused prepubertal children who have history or physical examination findings indicative of penetrating trauma

· In sexually abused prepubertal children who have been molested by a person at high risk for sexually transmitted disease

Screening Tests for Girls

· Serologic testing for syphilis

Human immunodeficiency virus (HIV) serology *

· Hepatitis B serology *

· Neisseria gonorrltocac cultures from vagina (or cervix in postpubertal females), mouth. and rectum

· chlamydia trachomatis cultures from vagina (or cervix in postpubertal females) and rectum

· culture and wet mount examination of vaginal swabs for Trichomonas  vaginalis

Wet mount examination of vaginal swabs for bacterial vaginosis

Screening Tests for Boys

Serologic testing for syphilis *

Human immunodeficiency virus (HIV) serology * Hepatitis B serology *

· Urethral swab culture for Neisseria gonorrhoeae if urethral discharge, dysuria, positive urine leukocyte esterase, or erythema present

· Urethral swab culture for Chlamydia trachomatis if urethral discharge, dysuria, positive urine leukocyte esterase, or erythema present

* Repeat in 12 weeks to exclude acquired infection more definlitirely.

4. Reporting:

A)Family Advocacy Social Worker for NNMC (CDO has the pager #, call 295-4611). The SW are now in Anacostia and that office number for daytime calls is 1-(202) 433-5032.

B)  Naval Criminal Investigative Service (295-0570 during the weekdays), after hours again, call the CDO at 2954611.

C)  CFS (see attached list) in county in which alleged abuse occurred.

D)  Local police in county the alleged abuse occurred (if alleged perpetrator is non-military).

5.    Disposition:

A)  Safety of the child is the most important issue.

B) If alleged perpetrator is not in the family home, they can go home, if well. If it is a family member, admit or have authorities intervene to remove this person from the home while the investigation proceeds.

C)  Keep copies of everything you wrote, including your hand-written notes, drawings, and final reports.

from an April 1998 lecture by CAPT Craig, MC, USN