Child Genital examination part 1 for sexual abuse

History

In incidents of child sexual abuse (CSA), the interview with the child is typically the most valuable component of the medical evaluation. Elicited history is frequently the only diagnostic information that is uncovered. Additionally, if performed in a sensitive and knowledgeable manner, the history-taking process can be a first step in the healing process for the child who is sexually traumatized. Regardless of the history provided, the members of the interdisciplinary team need to demonstrate an open, nonjudgmental, and caring attitude toward the child; the willingness to advocate for the child must be demonstrated as the evaluation unfolds.

• General principles for successful history taking

  • To assist in creating a comfortable and nonthreatening environment, allow an extended period of time when taking the history in children who are suspected of being sexually abused.
  • When interviewing the child, use a developmentally sensitive approach to the questioning so that the child can understand what is being asked and is able to answer as accurately as possible.
  • Rely on nonleading questions as much as possible to permit the child to relate information in a credible and reliable framework.
  • An interview often has a healing value for children, enabling them to start to feel some control with what occurs in their lives in contrast to the abusive situation that took away the control they should have with their own bodies.
  • In an effort to demystify the information-gathering process, consider permitting children to sit where they want to sit, slowing down the pace of the interview if it starts to go too fast, permitting time for play breaks, and encouraging children to use their own words for body parts.
• Initial introduction with efforts to build up trust

  • During the initial meeting, the health care provider and any members of the interdisciplinary team who are involved with the treatment of the child should introduce themselves to the child and caregiver.
  • At this point, the primary health care provider should explain how the evaluation usually proceeds, including the need to first speak alone with the caregiver and then alone with the child.
  • After these initial conversations, ask the caregiver to rejoin the child for a physical examination, which frequently is understood as a "check-up" by the child.
• Caregiver interview

  • Ensure that caregivers who accompany children have an opportunity to describe their concerns, provide information about the children's health, and outline any information they have related to the suspected abuse.
  • By interviewing the caregiver first, the interviewer allows the child an extra bit of time to become familiarized with the clinical setting and, hopefully, to become more comfortable with the environment.
  • Initially explain to the caregiver the extent to which the information elicited during the interview is required to be shared with child protective services (CPS) staff and law enforcement personnel who may be involved with the case.
  • Clarifying the limits of confidentially in suspected incidents of child sexual abuse is paramount to avoid feelings of betrayal later if and when information is shared with the various involved agencies.
• Child interview

  • When verbal children are interviewed when the caregivers are not present, children may not provide the most valuable information.
  • Using a sensitive approach and building on what has been learned in the warm-up and caregiver interview components, begin with nonthreatening topics such as favorite activities, school subjects, and personal interests.
  • Once rapport has been established in the interview, ask the children why they have come to the doctor's office.
  • By focusing on asking simply worded, open-ended, nonleading questions, the person taking the history can progress through the standard "what, when, where, and how" questions, which are important to the medical evaluation of suspected child sexual abuse.
  • The full potential of the interview can be realized by a reliance on such questioning as "tell me more" followed by "and then what happened?"
  • Supporting the child for working hard to answer the questions (but not for the content of the answers) is vital to the credibility of the information elicited.
  • The clinician must understand the developmental capacity of the child and work within the child's abilities to garner the information needed. Thus, children may not know dates but they remember holidays; children may remember something happened before or after school began.
  • Asking children to explain what they mean to avoid misunderstanding important points in the history is always appropriate.
  • Using the child's words for body parts may make the child more comfortable with difficult conversations about sexual activities.
  • Using drawings may also help children describe where they may have been touched and with what they were touched.
  • Meticulous documentation is a necessity for these types of histories, because the documentation may be considered as evidence in subsequent legal proceedings emanating from the overall investigation.
  • To the extent possible, document specific quotes that the child makes about the abusive events.
  • Often, entries made in medical charts by health care providers of children's words detailing their own sexual victimization assist those advocating for children as they argue for suitable protection from people and situations that may be threats to the children's well-being.
  • Consider videotaping or audiotaping the interview if the jurisdiction permits this.
• Wrap-up and preparation for the physical examination

  • After the child interview concludes, the caregiver can be invited back in the room to help facilitate the transition to the physical examination.
  • Being honest and empathetic with the child is critically important.
  • Therefore, do not promise that needles are not to be used unless absolutely sure that obtaining blood is not necessary; if not sure, reassure children that blood is obtained only if needed and, if blood is needed, children are told at the end of the examination.
  • Inform children if genital swabs are to be collected; allow them to handle the swabs in order to gain some comfort with the procedure.
  • If a colposcope is to be used during the physical examination, introduce it as a "special camera" that the doctor uses that does not touch the child.
  • After an appropriate discussion, leave the room and allow the child to prepare for the examination by suitable disrobing and putting on a gown with the caregiver's assistance.