Findings in Acute and Nonacute Exams of Adolescents

1. Findings in Acute and Nonacute Exams of Adolescents Marilyn Kaufhold, MD, FAAP

2. Learning Objectives

3. What is the role of the medical provider?

4. Obtain details of sexual acts and other circumstances

5. Types of Sexual Assault/Abuse (SA) • SA by acquaintance/ stranger /date • Drug-facilitated sexual assault (DFSA) • Continuation of child SA– incest, multiple incidents • Unlawful statutory intercourse • Prostitution-homeless teens, runaways • Trafficking • Sexual harassment – demands for sexual favors for jobs, grades, etc. • SA during armed conflict • Violent acts against women’s integrity, e.g.. Female genital cutting • SA in police custody, prison, refugee setting • Child marriage

6. Exam Parameters

7. Reminder: Genitalia Changes from Prepuberty to Puberty 15 yr 5 yr 15 yr

8. Reminder: Use Correct Anogenital Anatomy Terms

9. Reminder: Fossa Navicularis Groove is a normal finding 13 yr • Frequently seen in Tanner 3 and above • May be bordered by papillae • May be straight or branched • May be confused with trauma 13 yr

10. Reminder: Cervical Ectropion is a normal finding • Transformation zone • Border between mullerian-type columnar cells and squamous epithelium • Often seen in teens and in females using hormonal contraception • Don’t mistake for injury

11. Q: NO

12. Incidence/Types of Acute Genital Injuries in Adolescents

13. Injuries: Prior Sexual Experience vs. No Prior Sexual Experience *Exam Method: Toluidine blue dye/magnification 13

14. What does finding an injury mean? 14

15. Most Common Acute Injury Sites • #1 Posterior fourchette/ fossa navicularis • #2 Labia majora and minora • #3 Hymen • Other: vestibule, peri-urethral area, perineum, vagina, cervix

16. Acute Trauma to External Genital Tissue: History of Consenting Sexual Activity 13 yr 16

17. Method: Toluidine Blue Dye • Apply dye with a dye-saturated swab • Remove dye with cotton balls dipped in lubricant 42

18. Acute Trauma to External Genital Tissue: History of Sexual Assault Another term applied to this case based on the history is Drug Facilitated Sexual Assault (DFSA)

19. Acute Trauma to Body and External Genital Tissue: DFSA History with No Memory of Sexual Assault 15 yr

20. Acute Trauma to External Genital Tissue: History of Sexual Assault 20

21. Acute Hymen Injuries: Ecchymoses and Lacerations 21

22. Blunt Force Penetrating Trauma and Body Injury; DFSA history 14 yr 22

23. Blunt Force Penetrating Trauma: Sexual Assault History 6 days later Acute exam 23

24. Blunt Force Penetrating Trauma: Sexual Assault History 2 wk later Acute exam

25. Blunt Force Penetrating Trauma: Sexual Abuse History 25

26. Blunt Force Penetrating Trauma: Sexual Assault History debris 26

27. Blunt Force Penetrating Trauma: Sexual Assault History 2 weeks 6 hours 4 days All views are knee chest 27

28. Severe Injuries: Acute Exam 28

29. Blunt Force Penetrating Trauma: Paracervical Injury 29

30. Nonacute Exams: The Challenge!

31. Interpreting Nonacute Injuries: Hymen Clefts 31

32. The Evolution of Hymen Lacerations from Acute to Healed

33. This cleft appears to be complete (transection) consistent with prior trauma 33

34. This cleft appears to be deep but not complete: indeterminate

35. Incidence of Acute Anal Injuries in Adolescents 35

36. Blunt Force Penetrating Trauma: Sexual Assault History 36

37. Blunt Force Penetrating Trauma: Sexual Assault History

38. Blunt Force Penetrating Trauma: Sexual Assault History 38

39. Indeterminate Fissures vs. lacerations 39

40. Rectal Injuries: Medical/Forensic Significance 40

41. Anal/rectal Injury Image per anoscopy 58

42. Absence of Anal or Genital Injury 42

43. What to say when no signs of injury are found:

44. Care for the Sexually Abused / Assaulted Adolescent

45. Preparing the Medical Report and Formulating the Conclusion

46. Example: Blunt Force Penetrating Trauma and Body Injury; DFSA History • Care provider not present. • LE: Police car hailed by stranger who found partially dressed 14 y/o girl passed out in the park. Two males were running from the scene as he approached. Police subsequently identified her as a runaway. Unable to provide history to police initially because intoxicated. Taken to the Emergency Department. Human suction mark on her neck noted. 46

47. Example (con’t): Blunt Force Penetrating Trauma and Body Injury; DFSA History • History from teen victim: She ran away from home yesterday after an argument with her mother. She reported she and girlfriend accepted alcohol from two men who appeared to be in their 20s. She has no recollection of sexual activity. She denies engaging in any consenting sexual activity with the males who offered alcohol. Suction mark on her neck was not present before the incident. Genital area feels sore. • PMH, ROS, SH, FH: Oldest child of 3 sisters; lives with mom and her boyfriend who drinks; sexually abused by her biological father at age 5 yr.

48. Example (con’t): Blunt Force Penetrating Trauma and Body Injury; DFSA History • PE: Genital exam revealed extensive acute hymen bruising. Bruise that looks like a human suction mark noted on right side of her neck. • Lab: Evidence packet submitted to law enforcement. STD tests for GC, chlamydia, syphilis, HIV pending. • Assessment: Hymen injuries are characteristic of blunt force penetrating trauma: most likely mechanism is penile penetration. A person under the influence of alcohol is unable to give consent.

49. Questions?

50. References • Adams, J. A. (2001). "Evaluating children for possible sexual abuse." Am Fam Physician63(5): 843-844, 846. • Adams, J. A., A. S. Botash, et al. (2004). "Differences in hymenal morphology between adolescent girls with and without a history of consensual sexual intercourse." Arch Pediatr Adolesc Med158(3): 280-285. • Biggs, M., L. E. Stermac, et al. (1998). "Genital injuries following sexual assault of women with and without prior sexual intercourse experience." Cmaj159(1): 33-37.