M Medical Evaluation of Medical Evaluation of e d i c a l E v Child Sexual Abuse Child Sexual Abuse a l u a t i o n A PRACTICAL GUIDE 4th Edition o A PRACTICAL GUIDE 4th Edition f Editors: Martin A. Finkel, DO, FACOP, FAAP, C h and Angelo P. Giardino, MD, PhD, MPH, FAAP i l d The fourth edition of this best-selling reference is a valuable resource to S clinicians and child advocates serving children and families aff ected by e x suspicions of child sexual abuse. u Fully updated and revised by leading experts on child abuse, this resource a l covers what a complete and comprehensive medical evaluation entails, A when to seek an examination, the importance of conducting a medical b history, how discrepancies between a child’s history and physical fi ndings u s can be explained, how the child’s medical record should be structured, e what types of documentation should be expected, and how a medical 4A diagnosis is formulated. th EdPR NEW TOPICS INCLUDE itA ioC • Telemedicine and the child sexual abuse medical evaluation nT I • Human traffi cking C A • International issues in child sexual abuse L • Enhanced focus on fi ndings that mimic sexual abuse and on G U developmental considerations I D E Medical Evaluation of Child Sexual Abuse is an invaluable resource for medical professionals, child protection workers, mental health clinicians, investigators, and the courts. For other pediatric resources, visit the American Academy of Pediatrics G at shop.aap.org. iardFink inoel Martin A. Finkel, DO, FACOP, FAAP ISBN 978-1-61002-295-8 90000> Angelo P. Giardino, MD, PhD, MPH, FAAP AAP 9 781610 022958 Medical Evaluation of Child Sexual Abuse A Practical Guide 4th Edition Edited By Martin A. Finkel, DO, FACOP, FAAP Child Abuse Research Education and Service Institute School of Osteopathic Medicine Rowan University Stratford, NJ Angelo P. Giardino, MD, PhD, MPH, FAAP University of Utah School of Medicine Intermountain Primary Children’s Hospital Salt Lake City, UT American Academy of Pediatrics 345 Park Blvd Itasca, IL 60143 American Academy of Pediatrics Publishing Staff Mary Lou White, Chief Product and Services Officer/SVP, Membership, Marketing, and Publishing Mark Grimes, Vice President, Publishing Chris Wiberg, Senior Editor, Professional/Clinical Publishing Theresa Wiener, Production Manager, Clinical and Professional Publications Mary Louise Carr, MBA, Marketing Manager, Clinical Publications Published by the American Academy of Pediatrics 345 Park Blvd Itasca, IL 60143 Telephone: 630/626-6000 Facsimile: 847/434-8000 www.aap.org The American Academy of Pediatrics is an organization of 67,000 primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists dedicated to the health, safety, and well-being of infants, children, adolescents, and young adults. The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of care. Variations, taking into account individual circumstances, may be appropriate. Listing of resources does not imply an endorsement by the American Academy of Pediatrics (AAP). The AAP is not responsible for the content of external resources. Information was current at the time of publication. Brand names are furnished for identification purposes only. No endorsement of the manufacturers or products mentioned is implied. The publishers have made every effort to trace the copyright holders for borrowed material. If they have inadvertently overlooked any, they will be pleased to make the necessary arrangements at the first opportunity. This publication has been developed by the American Academy of Pediatrics. The authors, editors, and contributors are expert authorities in the field of pediatrics. No commercial involvement of any kind has been solicited or accepted in the development of the content of this publication. Disclosures: Drs Christian and Melville disclosed that they provide expert testimony in child abuse cases. Every effort has been made to ensure that the drug selection and dosages set forth in this text are in accordance with the current recommendations and practice at the time of publication. It is the responsibility of the health care professional to check the package insert of each drug for any change in indications and dosages and for added warnings and precautions. Every effort is made to keep Medical Evaluation of Child Sexual Abuse: A Practical Guide consistent with the most recent advice and information available from the American Academy of Pediatrics. Special discounts are available for bulk purchases of this publication. E-mail Special Sales at [email protected] for more information. © 2019 American Academy of Pediatrics All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means—electronic, mechanical, photocopying, recording, or otherwise—without prior written permission from the publisher (locate title at http://ebooks.aappublications.org and click on © Get Permissions; you may also fax the permissions editor at 847/434-8780 or e-mail [email protected]). Third edition published 2009; fourth, 2019. Printed in the United States of America 9-420/0419 1 2 3 4 5 6 7 8 9 10 MA0907 ISBN: 978-1-61002-295-8 eBook: 978-1-61002-296-5 Cover design by Linda Diamond Publication design by Linda Diamond Library of Congress Control Number: 2018947986 About the Editors Martin A. Finkel, DO, FACOP, FAAP Dr Finkel is a professor of pediatrics and the medical director and cofounder of the Child Abuse Research Education and Service (CARES) Institute at the Rowan University School of Osteopathic Medicine. The CARES Institute is a statewide resource to inform best practices in the delivery of medical and mental health diagnostic and treatment services. Dr Finkel is an internationally recognized authority on the medical evaluation and treatment of children who have been alleged to have been sexually abused. Dr Finkel has been instrumen- tal in developing the New Jersey statewide network of regional child abuse diagnostic and treatment centers. These centers of excellence provide services for children who have been sexually and physically abused and educate profes- sionals within the medical, child protection, law enforcement, and mental health communities on the evaluation of children who have been victimized. He has been a pioneer in the use of video colposcopy for the assessment and documentation of residua from sexual abuse. In the medical literature, he is the author of the first scientific paper published on the healing and interpretation of acute genital and anal trauma and the first paper on signs and symptoms associated with genital contact in girls. He has published numerous articles, authored chapters, and coedited 3 previous editions of Medical Evaluation of Child Sexual Abuse: A Practical Guide. Dr Finkel was appointed by 9 governors to cochair, with the commissioner of the Department of Children and Families, the New Jersey Task Force on Child Abuse and Neglect and 2 governor blue ribbon panels to review child protection practices. He is a founding commissioner of the New Jersey Children’s Trust Fund to prevent child abuse. Dr Finkel has been on the National Board of the American Professional Society on the Abuse of Children (APSAC), where he had oversight for the development of national standards regarding medical terminology and the interpretation of medical findings. He is a founding member of the Ray E. Helfer Society, the American Academy of Pediatrics Section on Child Abuse and Neglect, and the APSAC. He served a 6-year term on the National Board of Prevent Child Abuse America. He is former president of the American College of Osteopathic Pediatricians. Dr Finkel is a member of the Executive Committee and Council of the International Society for the Prevention of Child Abuse and Neglect. In 2012, he received the Ray E. Helfer Society lifetime achievement award and the US Department of Health and Human Services, Administration for Children and Families, commissioner award. In 2016, he received the Leonard Tow Humanism in Medicine Award presented by the Arnold P. Gold Foundation. iv About the Editors Angelo P. Giardino, MD, PhD, MPH, FAAP Dr Giardino is the Wilma T. Gibson Professor and chair of pediatrics at the University of Utah School of Medicine and chief medical officer at Intermountain Primary Children’s Hospital in Salt Lake City, UT. Immediately before this, Dr Giardino had been professor and section chief of academic gen- eral pediatrics at Baylor College of Medicine and senior vice president and chief quality officer at Texas Children’s Hospital in Houston, TX. While there, he served on the hospital Child Protection Team and helped staff the local child advocacy center. Dr Giardino earned his doctorates of medicine and philoso- phy at the University of Pennsylvania and his master of public health from the University of Massachusetts. Dr Giardino completed his pediatric residency and child maltreatment fellowship training at the Children’s Hospital of Philadelphia (CHOP) and also completed training in secondary data analysis related to child maltreatment through the National Data Archive on Child Abuse and Neglect Summer Research Institute at Cornell University. Dr Giardino’s clinical work focuses on child maltreatment, and in 1995, he collaborated with a multidisciplinary team to develop and lead the Abuse Referral Center for Children with Special Health Care Needs at the Children’s Seashore House, which was funded by a 3-year grant from a local philanthropy in Philadelphia. This program was designed to provide medical evaluations of children with developmental disabilities who were suspected of having been abused or neglected. In 1998, he was appointed associate chair for clinical operations in the Department of Pediatrics at CHOP and also served with the hospital child abuse evaluation service. In 2002, Dr Giardino joined the Department of Pediatrics at Drexel University College of Medicine as the asso- ciate chair for clinical affairs and was appointed associate physician in chief at St. Christopher’s Hospital for Children, where he also served as the medical director for the hospital Suspected Child Abuse and Neglect Program. This program collaborated with the Institute for Safe Families and Lutheran Settlement House to secure a Pennsylvania Children’s Trust Fund grant, which supported a community-based Intimate Partner Violence Screening Program at St. Christopher’s aimed at identifying at-risk families and working to prevent child maltreatment. In addition, while at St. Christopher’s, Dr Giardino collab- orated with colleagues at the Drexel University School of Public Health to launch the Philadelphia Grow Project, which provided clinical care to children with the diagnosis of failure to thrive and also conducted policy research on the issues surrounding food insecurity and childhood hunger. Dr Giardino is board-certified in pediatrics and is a fellow of the American Academy of Pediatrics. His academic accomplishments include published arti- cles and textbooks on child abuse and neglect, contributions to several national curricula on the evaluation of child maltreatment, presentations on a variety of pediatric topics at both national conferences and regional conferences. Most recently, he completed 2 terms on the National Review Board (NRB) for the v About the Editors US Conference of Catholic Bishops, providing advice on how best to protect children from sexual abuse. While on the NRB, Dr Giardino served as the chair for its Research Committee. Currently, Dr Giardino serves on the national boards of directors for Prevent Child Abuse America and the US Center for SafeSport. About the Contributors Alexander Butchart, PhD Dr Butchart is the prevention of violence coordinator in the Department for Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention at the World Health Organization (WHO) in Geneva, Switzerland. His responsibilities include coordinating the Global Campaign for Violence Prevention, the development of policy for the prevention of interpersonal violence, preparation of guidelines for the prevention of specific types of inter- personal violence, and the coordination of research into various aspects of interpersonal violence and its prevention. His postgraduate training includes a master’s degree in clinical psychology and neuropsychology and a doctoral degree for work examining the history and sociology of Western medicine and public health in southern Africa. Before joining WHO, he worked mainly in southern and East Africa, where he was lead scientist in the South African Violence and Injury Surveillance Consortium, and in collaboration with the Uganda-based Injury Prevention Initiative for Africa, he participated in training violence and injury prevention workers from a number of African countries. He has been a visiting scientist at the Swedish Karolinska Institutet Division of Social Medicine and is a widely published social scientist. Cindy W. Christian, MD, FAAP Dr Christian holds the Anthony A. Latini Endowed Chair in the Prevention of Child Abuse and Neglect at the Children’s Hospital of Philadelphia (CHOP). She is a professor of pediatrics at the Perelman School of Medicine at the University of Pennsylvania and serves as associate dean of admissions at the Perelman School of Medicine. Dr Christian completed her pediatric residency and child abuse pediatrics fellowship at CHOP, where she has spent her career. For more than 2 decades, she directed the child protection program at CHOP. She is a faculty director of the Field Center for Children’s Policy, Practice and Research at the University of Pennsylvania. Dr Christian is a past chair of the American Academy of Pediatrics Committee on Child Abuse and Neglect and past chair of the Subboard of Child Abuse Pediatrics for the American Board of Pediatrics. From 2010 to 2015, Dr Christian served as the first medical direc- tor for the Philadelphia Department of Human Services, leading the develop- ment of policies and strategies to improve the health of dependent children in Philadelphia. Rachel A. Clingenpeel, MD, FAAP Dr Clingenpeel received her bachelor of science from Duke University in 1998 in psychology and biology with a certificate in neuroscience. She then com- pleted a 2-year postbaccalaureate research program at the National Institutes of Health before attending medical school at the University of Virginia, from viii About the Contributors which she graduated in 2004. She completed her pediatric residency training and chief residency at Tulane University in New Orleans and fellowship in child abuse pediatrics at Brown University in Providence, RI. Dr Clingenpeel joined the faculty at University of Arkansas for Medical Sciences (UAMS) in fall 2012. She now serves as assistant professor of pediatrics at UAMS, as well as associate director for the Team for Children at Risk at Arkansas Children’s Hospital. Dr Clingenpeel’s practice as a child abuse pediatrician includes duties such as inpatient and outpatient evaluation of suspected child abuse and neglect, medical directorship of the new Emergency Department Sexual Assault Response Team, and education of other health care professionals as well as community partners regarding all aspects of child abuse and neglect. Sharon W. Cooper, MD Dr Cooper is a developmental and forensic pediatrician who cares for children and select adults with different abilities as well as those who have been victims of maltreatment. Dr Cooper retired from the US Army with the rank of colonel and holds adjunct faculty positions at the University of North Carolina at Chapel Hill School of Medicine and the Uniformed Services University of Health Sciences in Bethesda, MD. She has provided numerous lectures to medical, nurs- ing, mental health, judicial, social science, and investigative agencies, including the National Judicial College, the Federal Bureau of Investigation, the Australian Federal Police, and INTERPOL. Her primary areas of expertise include all areas of child maltreatment, child torture, and child sexual exploitation. Dr Cooper has published numerous chapters on the subject of child sexual exploitation and is the lead editor of one of the most comprehensive texts in the United States on this subject. She works with victims and families of children who have been the prey of all types of online and off-line exploitation. She is a board member of and consultant to the National Center for Missing and Exploited Children and has taught several thousand special victim unit and vice investigators for over a decade, on the victim vulnerability, health impact, and diverse forms of exploitation in sex trafficking. Dr Cooper has served as an expert witness in several hundred cases of child maltreatment and numerous cases within the past several years on behalf of victims of sex trafficking. Dr Cooper served as a task force member for the US attorney general on Defending Childhood, Children Exposed to Violence; was an invited speaker to the White House Summit on the United State of Women; and recently presented at the World Congress on Child Dignity in the Digital World, sponsored by the Vatican. She has provided testimony before the US Congress, the Italian Senate, the Russian Parliament (Duma), and the Ottawa House of Commons on child sexual exploitation. ix About the Contributors Esther Deblinger, PhD, CPC-CBT Dr Deblinger is cofounder and codirector of the Child Abuse Research Education and Service Institute and a professor of psychiatry and psychology at Rowan University School of Osteopathic Medicine. Her clinical research on the impact and treatment of child sexual abuse and other childhood traumas has been supported by funds from the National Center of Child Abuse and Neglect, the National Institute of Mental Health, and the Rowan University Foundation. In collaboration with Judith A. Cohen, MD, and Anthony P. Mannarino, PhD, she developed and extensively tested Trauma-Focused Cognitive Behavioral Therapy, a treatment approach that has evolved as the standard of care for youths and families affected by trauma. Introductory training for this treat- ment model has been available online since 2005, and this training has been accessed by more than 300,000 therapists across more than 120 countries worldwide. Dr Deblinger also successfully collaborated with Melissa K. Runyon, PhD, on the development and evaluation of another evidence-based treatment model for families at risk for physical abuse. She has served 2 terms on the board of the American Professional Society on the Abuse of Children, served as a founding fellow of the Academy of Cognitive Therapy, and currently serves on the advisory board for the Moore Center for Child Sexual Abuse Prevention at John Hopkins University. Dr Deblinger has coauthored numer- ous scientific publications, several widely acclaimed professional books, and a number of children’s books about body safety. Most recently, Dr Deblinger was recognized by the Association for the Advancement of Behavioral and Cognitive Therapies as a pioneer in the field. Karen J. Farst, MD, MPH, FAAP Dr Farst is a child abuse pediatrician at Arkansas Children’s Hospital. She is an associate professor in the College of Medicine, Department of Pediatrics, at the University of Arkansas for Medical Sciences (UAMS) and director for the university Center for Children at Risk. She is a past president of the National Children’s Alliance Board of Directors. She earned her bachelor of arts and doctorate of medicine from Texas Tech University and then completed a residency in internal medicine and pediatrics at UAMS. Following a child abuse fellowship at Cincinnati Children’s Hospital, she completed a master of public health at Fay Boozman College of Public Health at UAMS. Lori D. Frasier, MD, FAAP Dr Frasier graduated from the University of Utah School of Medicine and com- pleted a residency in pediatrics and fellowship in child abuse at University of Washington/Children’s Hospital of Seattle. She completed a fellowship in child abuse at University of Washington/Harborview Medical Center. She has been on the faculties of the University of Missouri/Columbia, the University of Iowa, and the University of Utah. Dr Frasier is board-certified in general pediatrics