Physical Examinations of Sexual Assault, Volume 2: Nonassault Variants and Normal Findings Pocket Atlas

By Diana Faugno, MS, RN, CPN, Mary J. Spencer, MD and Angelo P. Giardino, MD, PhD

232 pages, 555 images, 25 contributors

While examining suspected sexual assault survivors, it is important that investigators be able to accurately assess not only for those findings indicative of assault but also for normal or otherwise nonassaultive findings. The difference between normal and assaultive findings may be subtle, and assessing for normal findings in cases of suspected sexual violence may be challenging. That being the case, sexual assault investigators of every variety can benefit from a fast and accessible reference to support their evaluations.

Readers in medicine, law enforcement, and any organizations affiliated with sexual assault investigations will benefit from an extensive and accessible visual catalog of normal physical findings.

• Language: English
• Publisher: STM Learning
• Release date: Feb 15, 2016
• ISBN: 9781936590698

Diana Faugno, MS, RN, CPN

Diana Faugno, a Minnesota native, graduated from the University of North Dakota in 1973 with a degree in nursing and obtained an MSN in 2006. Her professional experience includes nursing in the Medical/Surgical, Labor and Delivery, Pediatrics, and Neonatal Intensive Care departments.

Book preview

SECTION I

PREPUBERTAL

Chapter 1

NEONATES AND INFANTS (0–3 YEARS OLD)

Diana K. Faugno, MSN, RN, CPN,

Carolyn J. Levitt, MD

Malinda Waddell, RN, MN, FNP

Mary J. Spencer, MD

Because the majority of examinations for sexual abuse result in normal findings, some experts have questioned the need for a medical examination, especially when the last incident of abuse may have occurred some time previously. There are several reasons why the medical assessment is recommended.

—Examination may reveal evidence of penetrative trauma.

—Reassuring the family that the examination findings are normal may reduce anxiety.

—In court proceedings, jurors and judges may perceive the lack of a medical assessment as an incomplete investigation, negating the importance of the victim’s statement.

—Some children are victims of repeated sexual abuse.

Examinations with photodocumentation allow for detection and comparison of changes that can occur over time.

—The presence of a previously undiagnosed sexually transmitted infection (STI), such as venereal warts, may be detected.

In order to recognize signs of child sexual abuse, it is necessary to first be familiar with normal genital anatomy, its variations, and its development. While this may seem obvious, the lack of understanding of the many variations in normal appearance of the genital and anal tissues in children has led to misunderstandings among medical and non-medical professionals alike. When a child’s examination is thought to show signs of injury or abuse but actually represents normal findings or evidence of another medical condition, the medical provider may contact child protection and/or law enforcement officials to report the suspicions. The child and family might then be unnecessarily traumatized by a referral and investigation of those suspicions.

NONASSAULT VARIANTS

ACCIDENTS

Case Study 1-1

This 2-year-old Caucasian was jumping on the bed when she fell, straddling the side rail. Her mother’s boyfriend was watching her while the mother was out running errands. The child was dressed and wearing a diaper while jumping on the bed. She was brought in within 12 hours of the accident.

Figure1-1-a

Figure 1-1-a. The diaper she wore on arrival for the exam (35mm).

Figure1-1-b

Figure 1-1-b. A laceration of the posterior fourchette (35mm).

Key Point:

Photodocumentation of clothing may support a history of force.

Figure1-1-c

Figure 1-1-c. A deep posterior fourchette laceration. There is focal erythema of the hymen at 3 to 5 o’clock and 7 to 10 o’clock. The labia majora and minora are free of injury that might be expected from a straddle fall.

Figure1-1-d

Figure 1-1-d. The child is draped for a surgical repair (35mm).

This case was canceled because it lacked elements of a crime.

Case Study 1-2

After bringing this 2-year-old female home from the babysitter, her mother saw that the baby’s bottom looked like raw meat. This explained why the baby was so irritable, especially with urination. The sitter said the child went all day without a diaper to try to potty-train. There was no history of falls or accidents, and there was no male in the house that day. The exam was conducted with-in hours of the mother identifying the child’s injuries.

Figure1-2

Figure 1-2. A large laceration in the labium majus that extends to the end of the labium minus.

This case was inactivated because all leads were exhausted.

Case Study 1-3

This 3-year-old female was brought in for an examination 12 hours after her mother noticed redness on her vagina. It was determined that the child was penetrated by another toddler when they were taking a bath together.

Figure1-3

Figure 1-3. The child is in knee-chest position. There are 2 sites of focal erythema, at 10 and 11 o’clock, on this thin, vascular hymen.

The case was canceled because it lacked elements of a crime.

LABIAL ADHESIONS

Case Study 1-4

There is a history of several weeks of digital contact to this 4-month-old by her natural father. The adhesions had not been treated at the time of the photograph.

Figure1-4

Figure 1-4. Labial adhesions with an anterior and posterior opening. Cultures were negative for Neisseria gonorrhea and Chlamydia trachomatis.

Case Study 1-5

This 2-year-old child had a history of blood in her diaper.

Figure1-5

Figure 1-5. Labial adhesions run from midlabia posteriorly. The anterior opening is not evident in the photograph. The posterior aspect of the labial adhesion is beginning to separate, evident as the examiner gently separates.

Case Study 1-6

This 30-month-old female is in knee-chest position.

Figure1-6

Figure 1-6. Labial adhesions are evident.

Case Study 1-7

This 4-year-old female was examined because of a report of being molested by her grandmother. The duration of the abuse was unknown.

Figure1-7

Figure 1-7. Labial adhesions which are only several millimeters in length.

FOREIGN OBJECT PENETRATION

Case Study 1-8

This Hispanic 3-year-old female was brought for a medical-legal examination because she would repeat no toque (don’t touch) when her mother washed or wiped her genitalia. The child explained that a bug crawled into me.

Figure1-8-a

Figure 1-8-a. There is white tissue or mucus projecting from the superior vestibule. The pink vascular hymen has a rolled edge at 3 to 7 o’clock.

Figure1-8-b

Figure 1-8-b. A white foreign body is protruding from the urethra. The periurethral area is intact and pink.

Figure1-8-c

Figure 1-8-c. The periurethral area after the foreign body has been removed. There is some bleeding from the urethra.

Figure1-8-d

Figure 1-8-d. The foreign body is vegetable matter as determined by pathology.

INFECTION

Viral

Case Study 1-9

This 3-year-old homeless child lives with her mother in shelters.

Figure1-9

Figure 1-9. There is extensive Herpes simplex type 2 (HSV-2) around her anus and on her perineum and labia majora (35mm).

Case Study 1-10

This female is 3 years old.

Figure1-10

Figure 1-10. The Condyloma acuminata in the perianal area is due to the human papillomavirus (HPV).

Case Study 1-11

This 3-year-old was living with her homeless mother in a public park and in shelters. There were many males and females with whom she could have had contact. She was brought for an examination by child protective services because of bumps on her bottom.

Figure1-11-a

Figure 1-11-a. The child is supine. There are 2 cauliflower appearing warty clusters of condyloma acuminata (HPV). One is on the periurethral area and the other on the posterior hymen. There are several isolated warts on the labia majora.

Figure1-11-b

Figure 1-11-b. Flat and sessile warts visible on the buttocks of the child. Gardnerella vaginalis and Group B Streptococcus were cultured from the vagina (35mm).

The mother was arrested on numerous counts, including child endangerment. The child was placed in foster care and began treatment for the warts.

Case Study 1-12

A 2-year-old female was referred by a clinic for a medical-legal examination because of the question of condyloma acuminata. There was no history of sexual abuse.

Figure1-12-a

Figure 1-12-a. A pink, thick hymen with a lacy, vascular pattern. There is an avascular area of the hymen from 6 to 8 o’clock.

Figure1-12-b

Figure 1-12-b. A close-up view of 2 of the larger lesions.

Biopsy of the lesions confirmed molluscum contagiosum, a viral eruption that resembles genital warts and occurs in toddlers, typically on the face and body. In sexually active persons, the lesions may involve the genitals.

Investigation revealed there was no crime, so the case was canceled.

Bacterial

Case Study 1-13

One of 2 twin 3-year-old girls was examined because of a report that the father had been molesting them over the last 3 days. The father was the main care provider because the mother was in an in-patient drug recovery