Podcast #172 - IPV Educators: Essentials of the Pediatric Sexual Abuse Examination

Katherine (Katie) Thompson from IPV Educators is discussing more pediatric abuse pearls.  Our focus this time is on the very sensitive subject regarding examination in pediatric sexual abuse.  Katie walks us through how we can interview and perform a preliminary exam before a complete exam by a forensic examiner.

As with our previous podcast, we are going to focus on listing the top pearls here but please listen to the podcast for the full details.

• Basic forensic interviewing can be performed by most healthcare professionals.
  • The stereotype is that this process is performed by highly trained individuals sitting in a recorded room with the child asking very specific questions.
  • In reality, we as the typical healthcare professional are not expected to perform such specific tasks and can use basic skills to obtain the needed information to perform the initial steps in appropriately identifying and managing these cases.
• Children love to please adults.
  • As a result, we have to make sure that we do not let this unintentionally impact the interview.
  • Avoid parents being involved in the process as their verbal and non-verbal language can be particularly problematic.
  • In that same regard, we must recognize and avoid non-verbal cues ourselves.
    • Positive body language examples include smiling, nodding, raising eyebrows, and leaning forward which can all make the child feel like you are enjoying the information and that it would please you if they gave more or elaborated further.
    • Negative body language such as crossing your arms, leaning back, frowning, making non-committal noises, or seeming disinterested in general will have the opposite effect in many cases which can also be detrimental.  
    • Neutral body language particularly by staying at eye level (or lower in some cases) can be very beneficial as it is a less intimidating position. 
• The actual questions will vary by situation, but a simple format can make all of the difference.
  • Dr. Thomas Lyon has the Ten Step Investigative Interview which can provide a concise method to standardize the initial questions.
  • There is an even more detailed discussion of this approach with a simple breakdown from Research Gate that is worth reviewing.
  • The really neat aspect is that these questions can be used in a variety of settings and not just pediatric abuse and neglect.
• When it comes to the physical, there are certain elements that we need to know.
  • Dr. Joyce Adams has written extensively on this including how normal findings can be seen frequently in cases of sexual abuse.
  • There was a recent update (2018) regarding some of these findings.
  • Unless there are genital complaints (such as discharge), do not perform a genital exam in sexual abuse unless the most recent assault was within the last 24 hours.
    • These children will still need your help and outpatient management, but it does not warrant immediate evaluation.
    • The 24 hours cutoff is for the patient to get testing while evidence is still most likely to be present (the sooner the better).
    • Note that some agencies may still try to urgently collect evidence even after the 24 hour window and it is wise to know local protocols.
    • Also, genital injuries can heal very rapidly (usually within the first couple of days).
• The hymen can have many normal variants.
  • A common myth is that the hymen can reflect someone's virginity but this is not accurate.
  • The updated article from Dr. Joyce Adams above demonstrates a wide variety of normal variants and is worth reviewing if this were to come up in discussion with family.
• Positioning children during the exam can sometimes be difficult.
  • Katie recommends Dr. Rich Kaplan's Medical Response to Child Sexual Abuse as a resource which provides an atlas in addition to other resources.
  • The labia majora is not very sensitive in prepubescent girls and can be firmly moved without creating pain by providing traction and moving them toward the legs laterally to help expose the labia minora and the hymen.
    • A trick that Katie suggests to see this area is to have the patient sit on the caregiver's lap and face out toward the person assessing them.
    • The caregiver can use their hands as stirrups to allow for a more natural approach that is still comfortable to the patient.
    • This can also allow the caregiver to be right there with the patient and comfort them.

There is always more to cover and we are always happy to help.  Make sure to post your questions and comments, but you can also reach out directly to Katie Thompson and IPV Educators directly!

​Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook.  Remember to look us up on Libsyn and on iTunes.  If you have any questions you can also comment below, email at [email protected], or send a message from the page.  We hope to talk to everyone again soon.  Until then, continue to provide total care everywhere.

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