Evaluation of the Sexually Abused Child: A Medical Textbook and Photographic Atlas

352 Pages·2010·23.31 MB·English

Evaluation of the Sexually
Abused Child
This page intentionally left blank
Evaluation of the
Sexually Abused
Child
SECOND EDITION
A Medical Textbook and Photographic Atlas
ASTRID H. HEGER, M.D.
Associate Professor of Clinical Pediatrics
University of Southern California School of Medicine
Executive Director
LAC/USC Violence Intervention Program
Los Angeles, California
S. JEAN EMANS, M.D.
Associate Professor of Pediatrics
Harvard Medical School
Chief, Division of Adolescent Medicine
Co-Director, Center for Young Women's Health
Children 's Hospital
Boston, Massachusetts
DAVID MURAM, M.D.
Professor of Obstetrics and Gynecology
State University of New York Health Sciences Center
Brooklyn, New York
CAROLE JENNY, M.D. CATHERINE KOVEROLA, Ph.D.
Professor of Pediatrics Assistant Professor of Psychology and Pediatrics
Brown University School of Medicine University of Southern California School
Director, Safe Child Protection Program of Medicine
Hasbro Children's Hospital Los Angeles, CA
Providence, RI
SUSAN POKORNY, M.D.
CAROLYN J. LEVITT, M.D. Chief Department of Obstetrics and Gynecology
Assistant Professor Kelsey Seybold Clinics
Department of Pediatrics Associate Clinical Professor of Pediatrics
University of Minnesota School of Medicine Baylor College of Medicine
St. Paul, MN Houston, TX
OXFORD
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Copyright © 2000 by Oxford University Press, Inc.
Published by Oxford University Press, Inc.
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All rights reserved. No part of this publication may be reproduced,
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Library of Congress Cataloging-in-Publication Data
Evaluation of the sexually abused child :
a medical textbook and photographic atlas/
[edited by] Astrid H. Heger, S. Jean Emans, David Muram ;
Carole Jenny . . . [et al., contributors]. —2nd ed.
p. cm. Includes bibliographical references and index.
ISBN 0-19-513126-6
1. Sexually abused children—Evaluation Atlases.
2. Child sexual abuse—Diagnosis Atlases.
I. Heger, Astrid. II. Emans, S. Jean, Herriot. III. Muram, David.
? , • ") [DNLM: 1. Child Abuse, Sexual—Diagnosis.
2. Child Abuse, Sexual Atlases.
3. Interviews—methods.
4. Physical Examination—methods.
WA 320 E915 1999] RJ507.S49E93 1999 618.92'85836075—dc21
DNLM/DLC for Library of Congress 99-13480
The science of medicine is a rapidly changing field. As new research and clinical expe-
rience broaden our knowledge, changes in treatment and drug therapy do occur. The
author and the publisher of this work have checked with sources believed to be reliable
in their efforts to provide information that is accurate and complete, and in accordance
with the standards accepted at the time of publication. However, in light of the possi-
bility of human error or changes in the practice of medicine, neither the author, nor the
publisher, nor any other party who has been involved in the preparation or publication
of this work warrants that the information contained herein is in every respect accurate
or complete. Readers are encouraged to confirm the information contained herein with
other reliable sources, and are strongly advised to check the product information sheet
provided by the pharmaceutical company for each drug they plan to administer.
987654321
Printed in the United States of America
on acid-free paper
Preface
The second edition of Evaluation of the Sexually Abused Child brings
new challenges to the editors and each of the contributors to this
volume. The fundamental challenge, however, remains the same: to
evaluate each child and family with an eye to science while main-
taining high standards of interviewing, medical evaluation, and diag-
nosis of child sexual abuse. Since the first edition was published eight
years ago, we have learned more about evaluating children for possi-
ble sexual abuse. We know the profound implications a diagnosis of
sexual abuse can have, and we understand normal genital anatomy
and the post-traumatic changes associated with sexual assault in
greater detail. Medical professionals, charged with the responsibility
of evaluating and protecting children, understand more than ever the
importance of peer review and the problems of inexpert diagnosis.
This new edition reflects advances in research and gains in expe-
rience. It offers an updated overview of the social system and the psy-
chological impact of sexual abuse, as well as the latest in interviewing
techniques, forensics, and the medical diagnosis of sexual abuse and
sexually transmitted diseases. In addition, we have more than dou-
bled the color atlas to cover sexual abuse of adolescents, patterns of
healing trauma, and further examples of normal anatomical varia-
tions and medical conditions. The expanded atlas, with over 250
plates, provides a full range of illustrations to aid medical profes-
sionals in the diagnosis of genital variations, disease, and trauma.
On rereading the Foreword to the first edition, we realize that
although there has been tremendous progress in the quality of in-
tervention for victims of child sexual abuse, the charge, the warn-
ings, and the challenge remain.
Los Angeles, Calif. A. H.
Boston, Mass. S. J. E.
Brooklyn, N.Y. D. M.
January 1999
v
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Contents
Introduction ix
Richard D. Krugman, S. Jean Emans, and Astrid Heger
Contributors xiii
1. Making the Diagnosis of Sexual Abuse: Ten
Years Later 1
Astrid Heger
2. The Child Protection System 11
Richard Krugman and Astrid Heger
3. Psychological Effects of Child Sexual Abuse 21
Catherine Koverola and William N. Friedrich
4. The Medical Interview 41
Carolyn J. Levitt
5. Physical Examination of the Child and Adolescent 57
S. Jean Emans
6. Forensic Examination: The Role of the Physician
as "Medical Detective" 79
Carole Jenny
7. Anatomy 95
Embryology of the Genital Tract 95
David Murom
Anatomic and Physiologic Changes 105
David Muram
Anatomical Terms of Female External Genitalia 109
Susan Pokorny
vii
Viii CONTENTS
8. Photographic Atlas 115
Normal Genitalia 115
Examination Positions and Techniques 116
Congenital Variants 116
Nonspecific Changes 117
Anatomic Variations and Medical Conditions:
Diagnostic Challenges 117
Acute Genital Trauma—Accidental 119
Female Genital Mutilation 119
Acute Genital Trauma—Sexual Abuse 119
Sexual Abuse—Delayed Disclosure 120
Normal Ani and Nonspecific Changes 120
Anal Trauma and Healing 121
Adolescents 121
Sexually Transmitted Diseases 122
9. Sexually Transmitted Diseases 187
David Muram and Deborah Stewart
10. Testifying as an Expert Witness 225
Kenneth R. Freeman
Glossary 241
Annotated Bibliography, 1992-1998 245
Appendices
A. State of California Sexual Abuse Protocol 269
B. Memphis, TN Sexual Abuse Protocol 275
C. Commonwealth of MA Sexual Abuse Protocol 281
D. Pilot Sexual Abuse Protocol, Children's
Hospital, Boston 288
E. Preappointment Questionnaire, University of
California, Irvine 300
E American Professional Society on the Abuse of
Children—Practice Guidelines: Descriptive
Terminology in Child Sexual Abuse Medical
Evaluations 302
Index 309
Introduction
RICHARD D. KRUGMAN, S. JEAN EMANS,
AND ASTRID HEGER
The last twenty-five years have been marked by a dramatic increase
in recognition of the problem of child abuse—especially sexual
abuse. In 1976 there were 35 reported cases of sexual abuse among
Colorado children; by 1986, the number of reports had exceeded
3,500. Substantiated cases in 1989 were nearly 2,000. Between 1989
and 1999, reported cases of child sexual abuse in the United States
rose to over 500,000 each year. What Kempe called "Another Hid-
den Problem" in his 1977 C. Anderson Aldrich Award Lecture at
the American Academy of Pediatrics Annual Meeting is clearly no
longer hidden.
Public and professional response to the problem has been
predictable. From denial of its existence through the desire to rec-
ognize, rescue, and treat the victim and to find, prosecute, and
incarcerate (and occasionally treat) the offender, individuals and
communities are grappling with a flood of cases so great that the
multidisciplinary child protection system (broadly defined—not just
the child protection agency) cannot hope to handle it.
Historically, physicians have been a part of the multidisciplinary
approach, and many were somewhat prepared to assist in the diag-
nosis of "battered children." We had training in recognizing frac-
tures, burns, and bruises, and could ferret out discrepant histories.
IX