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    Physical Examinations of Sexual Assault, Volume 1: Assault Histories Pocket Atlas
    Physical Examinations of Sexual Assault, Volume 1: Assault Histories Pocket Atlas
    Physical Examinations of Sexual Assault, Volume 1: Assault Histories Pocket Atlas
    Ebook692 pages1 hour

    Physical Examinations of Sexual Assault, Volume 1: Assault Histories Pocket Atlas

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

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    About this ebook

    236 pages, 666 images, 21 contributors

    In cases of sexual assault, it is important that investigators and care providers be able to respond quickly and appropriately in examining survivors, not only to ensure their health and safety but also to preserve any physical evidence left by the perpetrator. In such cases, a convenient visual reference can provide valuable support to investigators in making a timely and accurate assessment.

    With a convenient visual reference at the ready, sexual assault response team members in medicine, law enforcement, and in any other field involved with the investigation of sexual assault will be well prepared to make fast and effective assessments in the field.
    LanguageEnglish
    PublisherSTM Learning
    Release dateFeb 15, 2016
    ISBN9781936590681
    Physical Examinations of Sexual Assault, Volume 1: Assault Histories Pocket Atlas
    Author

    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.

    Read more from Diana Faugno, Ms, Rn, Cpn

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      Book preview

      Physical Examinations of Sexual Assault, Volume 1 - Diana Faugno, MS, RN, CPN

      SECTION I

      PREPUBERTAL

      Chapter 1

      NEONATE AND INFANT SEXUAL ABUSE (0–3 YEARS OLD)

      Diana K. Faugno, MSN, RN, CPN

      Carolyn J. Levitt, MD

      Malinda Waddell, RN, MN, FNP

      Mary J. Spencer, MD

      This chapter consists of cases of very young children within the approximate age range of newborn to 3 years. Sexual abuse in this age group often goes unreported. When it is reported, weeks or months may have passed since the abuse occurred. There are rarely conclusive physical findings, even in witnessed abuse, not only because of delays in reporting, but also because the sexual abuse of the young child is more often related to fondling than penetration. When there is acute injury, as would be more likely in attempted penetration of the infant’s vagina with the adult penis, it resolves quickly, without significant scarring of the mucous membranes.

      A medical examination should be performed as soon as possible after abuse is reported, even if weeks or months have passed since the incident. An examination with colposcopy and photodocumentation provides vital evidence for the current report and a baseline for the future. Photodocumentation also helps avoid repeated examinations. If photographs are available, Child Abuse Team members and consulting examiners can discuss the findings without retraumatizing the child. To accurately interpret the findings, the medical examiner must be familiar not only with the signs of abuse, but also nonassault variants and normal findings.

      ACUTE FINDINGS

      Case Study 1-1

      This 5-month-old female was brought to the emergency department the day after perineal bruises were found by the mother. A provider had sent her home with thick diaper cream completely covering these bruises. The mother noticed the bruises while changing the baby.

      Figure1-1-a

      Figure 1-1-a. 24 hours postassault shows ecchymosis posterior to the labia majora (35mm).

      Figure1-1-b

      Figure 1-1-b. General erythema of the hymen, periurethral area and medial labia minora. She has a patulous urethra.

      Figure1-1-c

      Figure 1-1-c. Five days after the first examination, there is resolution of the erythema.

      Case Study 1-2

      This 8-month-old female was cared for by a neighbor while the mother ran an errand. The neighbor was high on cocaine and attempted to penetrate the infant’s vagina with his penis.

      When the mother returned, the infant was crying and fussy. The mom found blood in her diaper.

      Figure1-2-a

      Figure 1-2-a. Hymenal ecchymosis, edema, and erythema are evident. An avulsion is present, midline at the base of the hymen, giving the appearance of a puncture wound.

      Figure1-2-b

      Figure 1-2-b. A laceration of the posterior fourchette from the perineum to the anus.

      Figure1-2-c

      Figure 1-2-c. Five days postassault, erythema of the vestibule persists. The cavity at the base of the hymen is filling with granulation tissue.

      Figure1-2-d

      Figure 1-2-d. Four months postassault. The injury at the base of the hymen has completely healed, and the annular hymen is thick. The erythema persists and is normal for this diapered infant.

      Case Study 1-3

      This is an 8-month-old Caucasian female, Tanner stage 1, examined within 6 hours of digital penetration of the anus and spanking. The 25-year-old male babysitter explained the baby wouldn’t stop crying. The first 4 photographs show the acute findings; the fifth photo was taken 3 months later.

      Figure1-3-a

      Figure 1-3-a. There is perianal ecchymosis and ecchymosis on the left buttock from 1 o’clock to 4 o’clock and on the posterior and lateral left thigh (35mm).

      Figure1-3-b

      Figure 1-3-b. Perianal ecchymosis is evident on both sides, lateral to the anus. There is ecchymosis on the right and left lateral thighs (35mm).

      Figure1-3-c

      Figure 1-3-c. This photo shows perianal ecchymosis, focal erythema superior to the anus, and lacerations at 12 and 6 o’clock.

      Figure1-3-d

      Figure 1-3-d. Toluidine blue dye uptake affirms the presence of the perianal lacerations.

      He was sentenced by court-martial to 8 years in prison.

      Case Study 1-4

      This 18-month-old Caucasian was observed by her 6-year-old sister being touched by her mother’s boyfriend. She was examined within 24 hours from the time of touching. There was a history of constipation.

      Figure1-4-a

      Figure 1-4-a. An annular hymen with symmetrical normal clefts at 3 and 9 o’clock. The vaginal wall is obvious within the hymenal opening.

      Figure1-4-b

      Figure 1-4-b. A perianal laceration at 12 o’clock which may be related to constipation.

      Case Study 1-5

      This 25 month old was examined within 24 hours after the foster mother brought her home from a day visit with her natural parents, who were drug abusers. There was blood found in her diaper and a red vagina. She had a history of constipation.

      Figure1-5-a

      Figure 1-5-a. A wide pocket-like laceration of the fossa navicularis and posterior fourchette extending from 6 to 8 o’clock. A second laceration extends from the posterior fourchette down the perineum.

      Figure1-5-b

      Figure 1-5-b. The perineal laceration extending downward to the anal tag at 12 o’clock.

      Figure1-5-c

      Figure 1-5-c. A coarse, kinky brown hair found on the genitalia. Cultures of the vaginal secretions revealed light staphylococcus species.

      The child was referred for a surgical consult. The mother, who gave several histories, was convicted by a bench trial and is serving a 2-year prison term.

      Case Study 1-6

      This 30-month-old Hispanic female was fondled by a friend of the family. She was examined in a supine frog-leg position 12 hours afterwards. Follow-up photographs are indicated to determine the significance of these acute findings. However, the mother refused to bring the child back.

      Figure1-6-a

      Figure 1-6-a. Edema of the clitoral hood and at the superior ends of the labia minora.

      Figure1-6-b

      Figure 1-6-b. Punctate erythema at 1 o’clock in the periurethral area. The erythema at the anterior commissure is evident as the labia are separated.

      Figure1-6-c

      Figure 1-6-c. An abrasion on the medial aspect of the labium minus.

      Case Study 1-7

      The child care provider found redness on the bottom of this nonverbal 24-month-old Caucasian female. Her older sibling (next case) revealed to the provider, Daddy touches us. The father cares for the children while the mother attends an in-patient drug recovery program. The child was examined within 48 hours of the disclosure.

      Figure1-7-a

      Figure 1-7-a. A large clitoral hood with focal erythema at 2 and 3 o’clock. Vaginal cultures demonstrated normal flora.

      Figure1-7-b

      Figure 1-7-b. Erythema from 3 to 9 o’clock in the vestibule.

      Case Study 1-8

      This 3-year-old child, sister of the child in the previous case, is developmentally delayed. She was born full-term at 4 pounds. Her mother used cocaine while she was pregnant. She was examined 24 hours after she disclosed to the child care provider that Daddy touches us.

      Figure1-8-a

      Figure 1-8-a. A large clitoral hood.

      Figure1-8-b

      Figure 1-8-b. Erythema from 6 to 9 o’clock on the vestibule, medial to the right labium minus.

      Key Point:

      Erythema is a nonspecific finding, but that does not rule out sexual abuse.

      Case Study 1-9

      This 3-year-old Hispanic female was found by her 4-year-old bro-ther in the next apartment with a 40-year-old neighbor. The neighbor had his pants down and the 4-year-old brother said, I saw his pee-pee, and, He sucked her. The 3 year old did not give a history. The child was examined within 24 hours of the incident.

      Figure1-9-a

      Figure 1-9-a. Blood in the anterior part of the crotch of the underwear (35mm).

      Figure1-9-b

      Figure 1-9-b. Abrasions superior and lateral to the clitoral hood.

      Figure1-9-c

      Figure 1-9-c. Erythema medial to the labia minora, lacerations at 6 o’clock in the posterior fourchette and lacerations at the posterior ends of both right and left labium minus. There is an abrasion on the right labium majus.

      Figure1-9-d

      Figure 1-9-d. Focal erythema at anus between 6 to 10 o’clock and at 12 o’clock.

      Figure1-9-e

      Figure 1-9-e. Toluidine blue dye uptake of the lacerations in the posterior fourchette and at the posterior end of the left labium minus. The toluidine blue dye in the medial labia has been blotted off. The extensive dye uptake is consistent with the history of cunnilingus. Clitoral hood edema is present as compared to the follow-up (Figure 1-9-g).

      Key Point:

      Oozing injuries may not take up toludine blue dye even though breaks in the skin are apparent.

      Figure1-9-f

      Figure 1-9-f. Dye uptake on 2 of the perianal lacerations at 8 and 9 o’clock. There are multiple other sites of dye uptake. Note the erythema of the surrounding tissue (following the examination) compared to Figure 1-9-e (prior to the examination).

      Figure1-9-g

      Figure 1-9-g. This photo was taken at a 2-week follow-up examination. There is healing of the labial lacerations with only a small laceration remaining. The erythema of the labia may be typical to this child. There is no distinct dye uptake.

      Key Point:

      Follow-up photographs provide a comparison that clarifies what is a normal finding for a particular patient.

      NORMAL AND NONSPECIFIC FINDINGS

      Case Study 1-10

      This 22-month-old Caucasian female was brought in by her mother over 72 hours after the alleged incident. The mother reported that the child told her that her fraternal grandmother touched me, as she pointed to her genitalia. On interview the child failed to repeat her complaints of touching.

      Figure1-10-a

      Figure 1-10-a. A normal exam.

      Figure1-10-b

      Figure 1-10-b. Labial separation shows erythema around the outer perimeter of the hymen, which is likely normal for this diapered infant. There is a periurethral band at 1 o’clock.

      Case Study 1-11

      This 23-month-old Caucasian’s father saw blood in her underwear. The child gave no history of being touched on or in her privates. The Emergency Department physician saw tears on the hymen, which were not evident to the Child Abuse Physician who also saw the child within hours of the Emergency Department examination.

      Figure1-11-a

      Figure 1-11-a. Erythema at the opening of the clitoral hood and on the medial labium minus, which may be normal for this child.

      Figure1-11-b

      Figure 1-11-b. A normal, symmetrical, vascular pattern on the medial labia and hymen. The hymenal tag with its base at 8 to 9 o’clock is adhered at 5 o’clock. A swab might be used to lift this tag from its 5 o’clock position, showing that it is indeed a tag and not a band. A band that has torn loose from its attachment may have explained the bleeding.

      Case Study 1-12

      This 28-month-old Asian female complained of pain on urination. In explaining the complaint, the child said that one of her mother’s employees, a 22-year-old male, had touched her under her clothes.

      Figure1-12-a

      Figure 1-12-a. A laceration of the right labium minus. The vestibule is homogeneous and pink.

      Figure1-12-b

      Figure 1-12-b. Lacerations on the right and edema on the lower half of the left labium minus. Toluidine blue dye would help demonstrate

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