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When suspicions of sexual abuse arise, the need for proper, specialized medical treatment is often an after thought. Far too frequently, the child's health is placed on the back-burner, while the primary focus is placed on the investigative process. Unfortunately, Maslow's Hierarchy of Needs are often forgotten by well-meaning law enforcement and child welfare investigators. While criminal and child welfare investigations are critical to public safety, the child's health and safety are paramount in these situations. Too many well-meaning investigators fail to see the importance of the specialized medical-forensic evaluation if they believe no injuries will be discovered or there is nothing to place in a "rape kit" to send to the crime lab. This could not be further from the truth. Properly trained pediatric medical-forensic providers have specialized training and equipment to accurately identify signs of old or healing genital trauma and sexually transmitted infections (STI's) in children and adolescents with no symptoms of such an infection, months and even years after the incident. At The Cottage, we provide specialized medical-forensic evaluations FREE of charge to any suspected child or adolescent victim of sexual violence in the state; however, we primarily serve the children residing in the 6 counties of the Atlantic Judicial Circuit: Bryan, Evans, Liberty, Long, McIntosh, and Tattnall counties. The latest statistical data related to STI's and HIV right here in our local service area may shock most parents and investigators:








Far too often, child and adolescent disclosures during the forensic interview are often erroneously relied upon when making the determination whether or not the child should be referred for a specialized medical-forensic examination. This is a major omission in the investigative process of child and adolescent sexual abuse cases. Documentation of the physical examination and STI testing are all critical pieces of evidence that can be utilized to identify suspected perpetrators or exonerate them, and investigations without these key pieces of evidence are incomplete. More importantly, unidentified and untreated STI's, including HIV, can have long-term, devastating consequences.







Despite what most parents, children, adolescents, and investigators may believe, the medical-forensic examination, when conducted by an appropriately trained pediatric medical-forensic provider, is not painful, invasive, or traumatizing to the patient. Do not allow this perception to deter you from seeking the proper specialized medical-forensic care for the suspected child victim of sexual abuse.


At The Cottage, we are available to you 24/7, and our services are provided FREE of charge to patients, their families, and any referring agencies that may be involved. No referral is needed by the child's primary care provider, and no approval from law enforcement or any other investigative agency is necessary or required. If you are a parent and your child or adolescent was a suspected victim of sexual abuse and was not referred to The Cottage by the investigating agency, contact us immediately. We will provide the individualized, trauma-informed, medical care your child may need FREE of charge to you. Our staff is also available to assist you with filing for any benefits you may be eligible for under the state crime victim's compensation program. Those benefits may financially enable you to seek much needed additional care and services you feel you otherwise would not be able to afford.


Finally, please remember that as the child's parent or guardian, you have a choice about who provides care to your child. If the medical-forensic evaluation that was offered by the investigating or any other agency involved in the process required you to travel further than our facility and/or simply was not an accessible option, please contact us. Our doctoral-prepared, pediatric medical-forensic examiners are highly experienced, board certified, independent practitioners who are ready and willing to provide the specialized care your child deserves and so desperately needs right here in their own community, FREE of charge.

Updated: Apr 17, 2019


Child and adolescent victims of sexual violence often have significant immediate and long-term medical and mental health needs that impact their health and well-being across the lifespan (Department of Justice Office on Violence Against Women [DOJ OVAW], 2016; Ports, Ford, & Merrick, 2016). Those who fail to receive proper medical and mental healthcare after sexual victimization are also at an increased risk for sexual re-victimization (Crawford et al., 2017). The negative sequela can, however, be mitigated with proper, evidence-based intervention. Timely, high-quality care provided by pediatric healthcare professionals who specialize in the evaluation and treatment of child and adolescent victims of sexual abuse is essential to improving the health outcomes of these young patients (Horner, 2010; Porta, Johnson, & Finn, 2017). Unfortunately, many of them fail to receive the specialized medical care they so desperately need.


According to the national standards for the care of suspected child and adolescent victims of sexual abuse, only a suspicion should trigger referral to a medical provider with specialized training and experience in evaluating sexually abused pediatric patients (DOJ OVAW, 2016). Most suspected and alleged incidences of child and adolescent sexual abuse are reported first to the local authorities, not healthcare providers; therefore, too many fail to receive the specialized medical attention they need, particularly if the authorities do not feel it would add evidentiary value to their case, the suspected victim failed to disclose to confirm the suspicions, previous disclosures have been recanted, or if the suspected/alleged incident occurred more than a week prior. There are many reasons why children and adolescents are not referred by the authorities for specialized exams in accordance with the national standards, but the most common are related to a lack of quality education regarding the purpose of and need for the medical-forensic examination, misconceptions regarding the extent and invasiveness of the examination process, and personal biases and assumptions despite proper education (ie: resistance to change).


Multiple studies have demonstrated the high rate of non-disclosure in forensic interviews with suspected child and adolescent victims of sexual abuse, providing justification for specialized medical evaluation based on a mere suspicion (McElvaney, 2013). Why is this important to the health and well-being of these children and adolescents? A recent systematic review of the literature revealed that only 43% of the pre-pubertal children (those who had not yet reached puberty) who tested positive for and were diagnosed with gonorrhea (a bacterial, sexually transmitted infection) made a disclosure of sexual abuse during their forensic interview (McElvaney, 2013). More recently, out of 1,319 suspected pediatric sexual abuse victims tested for sexually transmitted infections (STI’s), 59% of those who were positive for an STI in their anus/rectum and 77% of those positive for an STI in their throat did not report that the alleged perpetrator’s genitals came into contact with those orifices (Kellogg, Melville, Lukefahr, Nienow, & Russell, 2017). Based on those findings, Kellogg and her colleagues (2017) concluded that reliance on patient disclosure, report of symptoms, or types of sexual contact (ie: oral, vaginal, anal) to determine the need for and locations of STI testing in pediatric patients would result in failure to properly identify, diagnose, and treat those infections (which are contagious and if left untreated, can lead to permanent sterility).


The American Academy of Pediatrics recommend ALL suspected child and adolescent victims of sexual abuse should be examined by a pediatrician or nurse practitioner with sub-specialty training in the care of sexually abused pediatric patients (Crawford et al., 2017). In a national sample of pediatricians, less than half of those surveyed felt competent to care for sexually abused children and adolescents, and more than 85% of them preferred all suspected cases be referred to a local expert in the community (Dubowitz, Feigelman, Lane, & Kim, 2009). More recently, in a national sample of Family Nurse Practitioners (FNP’s) who provide primary care to children, only 25.5% felt comfortable performing examinations on suspected child and adolescent victims of sexual abuse, and 77.3% preferred to refer all of them to an expert in pediatric sexual abuse for further evaluation (Ceccucci, 2018). Only 17.3% of those FNP’s felt they were clinically competent to render a definitive opinion on their findings after evaluating a suspected child or adolescent victim of sexual abuse, and only 12.7% of those felt competent providing court testimony based on that opinion (Ceccucci, 2018). Unfortunately, only 75% of those FNP’s surveyed could identify a local resource available to refer their suspected child and adolescent victims of sexual abuse to for further evaluation (Ceccucci, 2018). Even more astounding, less than 50% of those who were aware of a local resource actually referred their patients who are suspected victims of sexual abuse to that resource (Ceccucci, 2018).


Timely, high-quality, evidence-based, specialized, medical-forensic care is essential to the health and well-being of any suspected child or adolescent victim of sexual abuse. The Cottage offers this service to children and adolescents FREE of charge to their families. Each of our patients are provided specialized, trauma-informed, comprehensive care in a community-based setting that is calming, child-friendly, and non-judgmental. Our staff takes the time required to answer all questions, address any concerns, and provide the individualized care all our patients and their families need and deserve. There are no co-pays or deductibles to fulfill. Your visit, any potential laboratory studies, and most medications (if indicated) are provided at no charge to our patients or their insurance companies. No referral from the patient’s primary care manager or law enforcement are required. Simply contact The Cottage, directly, for an appointment. We are also available to answer any questions you may have about this process. At The Cottage, we firmly believe in the healing power of a community-based response to trauma and violence…


References:


Ceccucci, J. (2018). Evaluating nurse practitioners perceived knowledge, competence, and comfort level in caring for the sexually abused child. Journal of Forensic Nursing, 14(1), 42-49. doi: 10.1097/JFN.0000000000000184


Crawford, J. E., Alderman, E. M., & Leventhal, J. M. (2017). Clinical report: Care of the adolescent after an acute sexual assault. American Academy of Pediatrics, Committee on Child Abuse and Neglect, Committee on Adolescence. Pediatrics, 139(3), e1-e11. Doi: 10.1542/peds.2016-4243


Dubowitz, H., Feigelman, S., Lane, W., & Kim, J. (2009). Pediatric primary care to help prevent child maltreatment: The Safe Environment for Every Kid (SEEK) model, 123(3), 858-864. doi: 10.1542/peds.2008-1376


Horner, G. (2010). Child sexual abuse: Consequences and implications. Journal of Pediatric Health Care, 24(6), 358-364.


Kellogg, N. D., Melville, J. D., Lukefahr, J. L., Nienow, S. M., & Russell, E. L. (2017). Genital and extragenital gonorrhea and chlamydia in children and adolescents evaluated for sexual abuse. Pediatric Emergency Care. doi: 10.1097/PEC.0000000000001014


Lane, W.G. & Dubowitz, H. (2009). Primary care pediatricians’ experience, comfort and competence in the evaluation and management of child maltreatment: Do we need child abuse experts? Child Abuse and Neglect, 33(2), 76-83. doi: 10.1016/j.chiabu.2008.09.003


McElvaney, R. (2013). Disclosure of child sexual abuse: Delays, non-disclosure, and partial disclosure. What the Research tells us and implications for practice. Child Abuse Review, 24, 159-169. doi: 10.1002/car.2280


Porta, C. M., Johnson, E., & Finn, C. (2017). Male help-seeking after sexual assault: A series of case studies informing sexual assault nurse examiner practice. Journal of Forensic Nursing, 14(2), 106-111. doi: 10.1097/JFN.0000000000000204


Ports, K.A., Ford, D.C., & Merrick, M.T. (2016). Adverse childhood experiences and sexual victimization in adulthood. Child Abuse & Neglect, 51, 313-322. doi: 10.1016/j.chiabu.2015.08.017


United States Department of Justice, Office on Violence Against Women. (2016). A national protocol for sexual abuse forensic examinations: Pediatric. Retrieved from: https://www.justice.gov/ovw/file/846856/download


Three questions most frequently asked by parents, Department of Family and Children Service (DFCS) case workers, and law enforcement personnel about the medical-forensic examination of suspected child sexual abuse victims are:


1) Who needs one?

2) Why do they need one?

3) Is it painful or traumatizing?


These are very important questions that every parent, DFCS case worker, and law enforcement officer should know the answers to. In this blog post we will answer those questions and provide the evidence-based rationale to facilitate a better understanding of who should receive medical-forensic care to help ensure pediatric patients get the sub-specialty medical-forensic care to which they are entitled FREE of charge to them.


WHO?


Suspected Child Sexual Abuse: No Disclosure Required

At The Cottage, our providers follow the nationally recognized, evidence-based guidelines established for the care of abused children and adolescents. According to those guidelines, if there is any suspicion of sexual abuse, regardless of whether or not the child or adolescent has made a disclosure or denial related to the allegations or suspicions, he/she should have a medical-forensic examination performed by a properly trained, pediatric medical-forensic provider in a child-friendly environment. No disclosure is required. A mere suspicion of child sexual abuse should trigger a referral to The Cottage for evaluation. Suspected child sexual abuse victims are not required to have a referral from law enforcement, DFCS, nor their primary care provider to receive care at The Cottage. Parents can make a referral simply by calling The Cottage to make an appointment.


Contact Children

The clinical practice guidelines also recommend that all “contact children” also have a medical-forensic examination conducted by a properly trained pediatric medical-forensic provider. A “contact child” is any child or adolescent who has had any type of in-person contact with the alleged perpetrator. To ensure the safety, health, and well-being of these children and adolescents, they should all have specialized medical-forensic examinations in the absence of disclosure and even when they deny any history of abuse.


Children Residing in or Visiting Home with Child Pornography

The clinical practice guidelines also state ALL children and adolescents residing in a home or who frequently visits a home where child pornography was discovered/confiscated should be scheduled for a medical-forensic evaluation with a properly trained, pediatric medical-forensic provider. To ensure the health, safety, and well-being of these children and adolescents, they should all have specialized medical-forensic examinations in the absence of disclosure and even when they deny any history of abuse.


WHY?


Pediatric medical-forensic providers have special equipment and specialized training to perform and document forensic-medical examinations on child and adolescent patients. The main objective of the medical-forensic evaluation is to ensure the health and well-being of the child or adolescent. First, it is not uncommon for children and adolescents to deny the abuse and subsequently test positive for a sexually transmitted infection (STI) and/or have significant genital findings. Secondly, children sometimes fail to have any symptoms of STI’s, and if left untreated, could lead to serious infections and sterility in adulthood. Finally, children and adolescents who have been abused often worry that they are different from their peers. The medical-forensic exam will help to reassure your child or adolescent that everything is okay with their body, and it also provides an opportunity to document any significant physical and/or forensic findings, which may be utilized as evidence in investigations and legal proceedings to convict or exonerate the accused. Our providers at The Cottage are highly trained and experienced in diagnosing and treating medical conditions related to abuse and also distinguishing these conditions from those that mimic abuse.


Is It Traumatizing or Painful?


No part of the medical-forensic examination should cause your child or adolescent any pain, nor should it be traumatizing in any way. It is important for you and your child or adolescent to understand that the genital exam is very different and far less invasive than an adult pelvic exam, and it is absolutely in no way comparable to a “pap smear.” Vaginal speculums are not inserted inside children and young adolescents. Patients are never forced, and they are given as much time as necessary to feel comfortable with the exam. If your child or adolescent is very resistant, the exam can be rescheduled for a later date or not done at all. Most children and adolescents are cooperative when they are reassured that the decision to have the exam is ultimately their own. Please be assured that your child or adolescent will always be treated with dignity and respect.

Richmond Hill, Georgia

Phone: (912) 445-2517

Email: admin@thecottagerh.org

© 2020 The Cottage at Serenity Hill, Inc. & Ingram-Jones & Associates, LLC

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