The National Protocol for Sexual Abuse Medical Forensic Examinations—Pediatric is a guide for: (1) health care providers who conduct sexual abuse medical forensic examinations of prepubescent children; and (2) other professionals and agencies/facilities involved in an initial community response to child sexual abuse, in coordinating with health care providers to facilitate medical forensic care. The main goals of a pediatric sexual abuse medical forensic examination, as described in this protocol, are to:
- address the health care needs of prepubescent children who disclose sexual abuse or for whom sexual abuse is suspected;
- promote their healing; and
- gather forensic evidence for potential use within the criminal justice and/or child protection systems.
It is also essential during the exam process to address concerns regarding children’s safety, as well as to offer emotional support, crisis intervention, education, and advocacy to children and their caregivers as needed. Coordination across disciplines and agencies/facilities in a community, as well as across jurisdictions in some instances (e.g., in concurrent federal and tribal cases), is crucial to simultaneously address the above health, legal, safety, and support goals.
About this Document
The OVW funded the International Association of Forensic Nurses (IAFN) to coordinate the development of the National Protocol for Sexual Abuse Medical Forensic Examinations—Pediatric. Leveraging the expertise of professionals involved in a community response to child sexual abuse at the local, state, federal, tribal, and national levels, including providers and organizations from health care and other relevant disciplines, was critical to protocol planning (as described below). The IAFN and the OVW also partnered with other U.S. Department of Justice (DOJ) agencies and federal agencies outside of the DOJ. The goal was to build upon their existing initiatives in responding to child sexual abuse and utilize the relationships they had established with organizations and experts around the country who serve this victim population.
Starting in the fall of 2014, the IAFN began gathering information and resources on protocols and practices related to pediatric sexual abuse medical forensic examinations. Over the course of protocol development, it solicited input on issues, gaps, and promising practices from an advisory committee, as well as numerous organizations, associations, and individuals.
- The advisory committee, formed in December 2014, included representation from child abuse pediatricians, pediatric sexual assault nurse examiners (SANEs), children’s hospitals, hospital emergency departments, children’s advocacy centers, community sexual assault victim advocacy programs, law enforcement agencies, prosecutors, and various groups that speak on behalf of specific populations. This committee assisted the IAFN and the OVW in: identifying and gathering supporting documents and data that informed decision making related to protocol scope, framing, and content; identifying issues and gaps in guidance for responders involved in the pediatric exam process; identifying potential elements of the protocol; and considering how to design the protocol to include needs of children with specific circumstances and from specific communities.
- Two work group meetings held in March 2015 generated a wealth of information and insight. These meetings called upon practitioners involved in health care, children’s advocacy, victim advocacy, criminal justice, child protection, and forensic sciences fields to assist in crafting the national protocol. Numerous medical and nonmedical professionals involved in the work group meetings were able to address medical forensic care and coordinated response issues for different populations of child victims.
- Several phone conference discussions with victim advocates and other service providers took place after work group meetings to gain additional victim perspectives on the initial community response to disclosures and suspicions of child sexual abuse and to more fully understand barriers facing child victims from specific populations.
A preliminary draft of the protocol was developed in July 2015 and was distributed to a wide array of individuals and organizations for their review. Reviewers were selected based on a number of factors: their expertise on the topic of pediatric sexual abuse medical forensic care or some aspect of the community response to prepubescent child victims; their representation of particular populations (e.g., victims, community, or institutional setting); or their representation of entities that would be asked to play a role in the distribution and/or implementation of the protocol. DOJ partner agencies were also involved in the review process. Comments received from reviewers were incorporated into the document as appropriate. For a listing of individuals involved, see Appendix 10. Participants in Protocol Development.
Protocol recommendations are organized into two broad sections:
- Section A. Foundation for Response During the Exam Process focuses on guiding communities in laying a foundation of approaches and practices that support successful response during the exam process to disclosures or suspicions of sexual abuse in prepubescent children, and
- Section B. Exam Process focuses on the various components of the sexual abuse medical forensic exam process.
Readers may be tempted to proceed directly to Section B for specific exam process guidance, however, Section A is important to review as it speaks to framing and infrastructure issues that communities should consider when creating a sexual abuse medical forensic examination protocol for prepubescent children. Sections A and B are comprised of chapters that discuss elements essential to those sections and offer related recommendations and considerations. Each chapter builds on previous chapters. Although an effort was made to avoid repetition of information, data may be repeated for clarity or emphasis.
Protocol Approach to the Examination
Key points to know regarding this protocol’s approach to the medical forensic examination include:
- Although the protocol’s focus is on the exam process, it also speaks to the initial community response to prepubescent child sexual abuse, as it is a gateway for victims to access medical forensic care. The protocol also acknowledges the necessity of a comprehensive, coordinated community response to fully address the needs of children specific to their individual circumstances. Planning at the conclusion of the examination can help connect children and their families to resources and prepare them for next steps in the community response.
- The protocol promotes multidisciplinary response teams and partnerships with children’s advocacy centers, where available, as tools to foster coordination and communication in these cases across disciplines and agencies/facilities, both in a community and across jurisdictions as needed.
- Although some prepubescent children disclose their experiences of sexual abuse, many do not or cannot. This protocol stresses that a suspicion of child sexual abuse should be all that is needed to trigger community interventions—including, but not limited to, medical forensic care, child protection, criminal investigation, victim services, and mental health care.
- Communities must be cognizant of and responsive to “contact” children—other children beyond presenting victims who may have had contact with, and possibly been abused by, the perpetrator (e.g., the siblings of a child sexually abused by a family member). This protocol encourages a multidisciplinary, collaborative approach, jurisdictional and multijurisdictional as applicable, to identify and sensitively address the needs of contact children.
- This protocol affirms that a medical forensic examination should be accessible to all prepubescent sexual abuse victims, regardless of the child’s background, circumstance, or geographic location. Due to the adverse health consequences associated with child sexual abuse as summarized later in this chapter, it is imperative that children who disclose sexual abuse or are suspected of being sexually abused receive timely health assessment, treatment, and interventions, regardless of the probability of evidence on their bodies or clothing.
- The protocol speaks to the fact that, due in part to the timing of disclosures, individual cases can vary in the urgency of medical forensic care necessary—meaning that the need for medical forensic care may be acute or nonacute. Generally, an acute examination should be conducted within the time frame prescribed by the jurisdiction, if a possibility exists that evidence may be present on the child’s body or clothing OR if factors beyond that time frame indicate a need for acute medical forensic care (one example is the child’s or the caregiver’s perception of urgency of the need for care). In most jurisdictions, a child is referred for a nonacute examination if the abuse occurred beyond the jurisdictional time frame for an acute examination AND no indication exists for acute medical forensic care. The protocol directs health care providers—rather than law enforcement or child protective service representatives—to determine the urgency of care appropriate for a child. Exam findings should always be documented, regardless of whether forensic samples are collected or whether the care provided is acute or nonacute.
- As prepubescent children typically present for health care accompanied by a caregiver, this protocol speaks to responders’ interactions with caregivers during the exam process. It stresses the need not only to aid caregivers and other family members in supporting the victimized child in the healing process, but also in dealing with their own reactions to the sexual abuse. In addition, it discusses safety measures if it is disclosed or suspected that a person accompanying the child during the exam process is the perpetrator, in collusion with the perpetrator, or otherwise abusive of the child.
USE OF TERMS
Note that the protocol uses a variety of terms and acronyms. The terms are described in the text and footnotes of the protocol, and the acronyms are spelled out the first time they are used, yet room for confusion may remain. For clarification, select terms are included in the glossary and a list of acronyms is provided.
- CAREGIVER refers to a person exercising a day-to-day caregiver role for a prepubescent child, such as a parent, guardian, foster parent, older sibling, relative, or family friend. Additional persons may play a temporary caregiver role for the child, such as a child care provider or babysitter. Note that a caregiver may or may not have legal responsibility over the child. Parents generally have the responsibility to make legal decisions that may be necessary for their children’s welfare, with jurisdictional laws defining exceptions. However, if prepubescent children do not have a parent who is qualified according to jurisdictional laws to make legal decisions on their behalf, they may need a separate individual to attend to their legal rights. In such instances, a guardian may be chosen voluntarily by the family or appointed by the court to make legal decisions for them. For this reason, when discussing consent issues, the terms parent and guardian may be used rather than caregiver.
- CHILD SEXUAL ABUSE: Child sexual abuse, as used in this protocol, is intended to encompass any sexual act a prepubescent child may experience, with the exception of developmentally appropriate sexual behaviors that may occur among children, as described in
B3. Entry into the Health Care System. Specifically, child sexual abuse refers to the involvement of a child in sexual activity that she/he does not fully comprehend and is unable to give informed consent, or for which the child is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society (World Health Organization [WHO], 1999). It can occur between a child and a person or persons of any age or relationship to the child. The general intent of the sexual abuse is to gratify or satisfy the needs of the other person(s) (WHO, 1999). (See the
Introduction for a discussion on the nature of child sexual abuse acts.) Note that the term CHILD SEXUAL ABUSE often has a different meaning across jurisdictions and clinical settings—for example:
- Jurisdictions vary in statutorily defined child sexual abuse acts as well as language used to describe these acts. See www.childwelfare.gov/topics/systemwide/laws-policies/state/ for differences across states and territories. American Indian and Alaska Native tribes often have tribal codes defining child sexual abuse—see www.tribal-institute.org/lists/codes.htm for links to select resources. See www.justice.gov/criminal-ceos/citizens-guide-us-federal-law-child-sexual-abuse for U.S. federal laws related to child sexual abuse. Note the U.S. federal statute, 18 U.S.C. § 2246, broadens the intent of sexual abuse to include “to abuse, humiliate, harass, degrade, or arouse or gratify the sexual desire of any person.” Criminal justice and child protection systems utilize their jurisdiction’s statutory definitions. Factors such as the age of child victims and/or perpetrators (if they are minors), the relationship between victims and perpetrators, and the specific nature of the acts can influence what a jurisdiction considers illegal. Regardless of whether a specific sexual abuse act is considered illegal in a jurisdiction and requires justice intervention, however, it is imperative that the child receive medical intervention due to the adverse health implications associated with child sexual abuse (as discussed in the Introduction).
- Clinically, the age and developmental level of child victims can impact whether they are cared for by health care providers trained in pediatric versus adult/adolescent medical forensic care.
- The EXAM PROCESS refers to the child’s entry into the health care system, the medical forensic examination in its entirety, and planning at the exam’s conclusion to facilitate post-exam health care and referrals to address child, family, and case needs.
- PEDIATRIC (adapted from Stanton & Behrman, 2011): Generally concerned with all aspects of the wellbeing of children. The pediatric population addressed in this protocol is solely prepubescent children as described below. Pediatric health care must be concerned with particular organ systems and biological processes, developmental issues, and environmental and social influences that affect the health and wellbeing of children and families.
- PREPUBESCENT: A child’s stage of pubertal development is determined by assessing secondary sexual characteristics rather than chronological age. Although the onset and timeline of the pubertal process is unique to each child, the stages are identifiable and predictable (Fritz, 2011; Jenny, 2011; Kaplowitz, 1999). TANNER STAGES detail the physical signs of breast, pubic hair, and male genitalia development for the five sexual maturation stages (Child Growth Foundation, n.d.; Marshall & Tanner, 1969). (See Appendix 1. Tanner Stages of Sexual Maturation) The sexual characteristic development of prepubescent children is reflected as Tanner stage 1 or stage 2. During the medical forensic examination, children require interventions that are tailored to their developmental stage. In addition, these interventions must be based on population-specific knowledge of development and differences between normal variants and healed injuries from prior abuse.
- Pubertal development is a natural differentiation between adolescents and prepubescent children. As indicated above, this protocol focuses on Tanner stage 1 and 2 children. ADOLESCENTS, as defined in this document, are children who are Tanner stage 3 and above who have potential reproductive capability. A Tanner stage 3 or 4 biological female, even if premenarchal, potentially has reproductive capacity.
- Adolescent victims as defined above are NOT addressed in this protocol, but in the adult/adolescent protocol available at www.ncjrs.gov/pdffiles1/ovw/241903.pdf. However, note:
- Treatment of Tanner stage 3 and 4 children requires calculated clinical decisions that take into account children’s developmental level in addition to sexual maturation stage . Despite their potential reproductive capacity—an issue that is addressed in the adult/adolescent protocol—Tanner stage 3 and 4 children are still children. As such, they should receive specialized medical forensic care that speaks to their developmental needs. There may be additional reasons in individual cases to involve a pediatric examiner when examining an adolescent (e.g., to recognize findings of healed anogenital trauma in an adolescent for whom abuse is the only form of sexual contact that has occurred).
- Female children who have not reached the onset of menses should be examined by health care providers specifically trained in pediatric sexual abuse.
- Female children who are premenarchal must not have a speculum examination, unless there is associated trauma requiring surgical involvement.
- Extreme care should be taken when deciding to do a speculum examination on a young postmenarchal adolescent, in order to prevent further injury, pain, or trauma.
- PREPUBESCENT CHILDREN WHO DISCLOSE SEXUAL ABUSE OR FOR WHOM SEXUAL ABUSE IS SUSPECTED” may also be referred to as CHILD SEXUAL ABUSE VICTIMS. Note that because the protocol addresses a multidisciplinary response to child sexual abuse, “victim” is not used in a strictly criminal justice or child protection context. Rather, its use simply acknowledges that children who disclose sexual abuse or for whom sexual abuse is suspected should have access to certain services and interventions designed to address their health care needs and help them be safe, heal, and seek justice. In a health care context, these children may be referred to as PATIENTS.
Note that when caregiver involvement in exam process is discussed in the protocol, it is generally within the context of a caregiver who is not suspected of being the perpetrator of the sexual abuse (a nonoffending caregiver). That said, it is often unknown by initial responders whether sexual abuse of a prepubescent child actually occurred and/or, if so, who is the perpetrator. Equally important to note is that it is not the role of health care providers or other non-investigative entities to make such determinations. However, if it is suspected that the caregiver or other person accompanying a child during the exam process is the perpetrator, in collusion with the perpetrator, or otherwise abusive of the child, it is critical that the child is protected from that individual. In addition to urgent outreach to law enforcement and child protective services to convey specific safety concerns, health care providers should follow their facility policy on response to this type of threatening situation. Note that the main safety concern in such situations is usually imminent danger of child abuse; there also may be a risk of danger posed to others at the health care facility. It is important that health care facilities and providers have the ability in such situations to create a safety plan for/with the child, including but not limited to the child’s admission to the facility when necessary (if the facility has inpatient capacity).
Protocol Recommendations for Standardized, High-Quality Examinations
This protocol offers recommendations to facilitate standardized, high-quality sexual abuse medical forensic examinations of prepubescent children, as well as coordination across disciplines, involved entities, and jurisdictions as applicable, to address child, family, and case needs during the exam process. Note:
- Recommendations are provided for baseline practices as well as “gold standard” practices where they have been identified. The intention is to inspire jurisdictions to “reach for gold” while ensuring a solid base. To the extent possible, recommendations are evidence-informed—meaning based on available evidence from research, but also on an understanding of related issues and responder experiences. To that end, where little or no research support practices, protocol developers looked to experts for consensus. However, consensus simply does not exist on every practice. Communities often have unique and/or different ways of responding to child sexual abuse. The protocol recommends following jurisdictional and/or health care facility policies in many instances, recognizing that multiple valid ways may exist to handle a particular issue.
- This document can aid communities in developing or revising protocols for providing sexual abuse medical forensic care for the prepubescent child. It supplements but does not supersede protocols that have been created at the local, state, territorial, tribal, and federal levels, or by national and international entities. To the extent appropriate, this protocol builds upon the National Protocol for Sexual Assault Medical Forensic Examinations—Adults/Adolescents.
- Although the protocol strives to be inclusive of related issues and needs of different types of communities, institutional settings that house or care for children, and diverse populations of child victims, the recommended practices may need to be tailored for local communities and different populations and settings.
- This protocol is meant to improve the prepubescent child sexual abuse medical forensic exam process, and the criminal justice and child protection systems’ response to prepubescent child victims. It does not address other civil justice remedies that may be available to these children (e.g., restraining orders or temporary custody arrangements) and does not create a right or benefit, substantive or procedural, for any party.
- The protocol is not intended as a comprehensive primer on the issue of child sexual abuse nor as training curricula for health care providers or responders from other disciplines. However, it does introduce readers to the topic and offers a wealth of information—for communities, agencies, organizations, and facilities involved in the response to child sexual abuse, and for institutions that house or care for children—to consider as they develop related policies and staff training.
- Finally, many of the laws that may impact medical forensic care—such as mandatory reporting, medical records privacy, consent to health care, and privileged communications—vary significantly from jurisdiction to jurisdiction. Although these laws are discussed in general terms throughout this document, health care providers should consult an attorney who is familiar with the laws of their health care facility and jurisdiction.
Protocol Focus on Children
Prepubescent children experience sexual abuse across multiple settings within the home, community, and broader society (Day & Pierce-Weeks, 2013; East, Central, and Southern African Health Community, 2011; Population Council, 2008). The nature of the sexual abuse may be affected by a variety of factors, including but not limited to those listed below.
Examples of Factors that Can Influence the Nature of Sexual Abuse (not inclusive)
(Note: The general intent of sexual abuse acts is to “abuse, humiliate, harass, degrade, or arouse or gratify the sexual desire” of the perpetrator or any involved person. These acts do not encompass activities that occur in the course of appropriate child care or medical care, or developmentally appropriate sexual behaviors of children, as described in B3. Entry into the Health Care System. Acts listed below are not legal definitions and are intended as examples.)
FREQUENCY AND SCOPE OF VICTIMIZATION
NUMBER AND CHARACTERISTICS OF PERPETRATORS
Note that being sexually abused by someone of the same or opposite sex, sexual orientation, or gender identity may create questions or confusion for children (National Child Traumatic Stress Network, 2014).
Sexual abuse of children is different from sexual victimization of adults. An impetus for this protocol was the fact that child sexual abuse differs from sexual assault of adults and adolescents; the difference compels a response to child sexual abuse that is tailored for children (Christian, Lavelle, & De Jong, 2000; Day & Pierce-Weeks, 2013; Girardet, 2011; Palusci et al., 2006; WHO, 2003; Young et al., 2006). Children are not little adults.
Sexual abuse against prepubescent children is distinct, particularly due to their dependence on their caregivers and the ability of perpetrators to manipulate and silence them (especially when the perpetrators are family members or other adults trusted by, or with power over, children). Very young children and children with disabilities who have increased reliance on caregivers are particularly at risk (CDC, 2015a). Sexual abuse may be a single encounter, but often it is ongoing over many weeks, months, or even years due to perpetrators’ unfettered access to and control over their victims. Episodic sexual abuse may become more invasive over time as perpetrators gradually sexualize their relationship with their victims (WHO, 2003). Sexual abuse is often hidden by perpetrators, unwitnessed by others, and may leave no obvious physical signs on child victims (Allnock, 2010; WHO, 2003).
Getting help is complex. There are many barriers to the reporting of sexual abuse for children (NSVRC, 2012b). (See the examples below.) Prepubescent children, by nature of their development, may be incapable of or have difficulty with identifying sexual abuse, communicating with others about it, and knowing how and having the capacity to access help. These difficulties can be exacerbated for children with disabilities (Smith & Harrell, 2013). Prepubescent children may also have much lower tolerance than adolescents or adults for activities associated with seeking assistance from unfamiliar people.
Examples of Reasons Why Children Do Not Disclose Sexual Abuse
Barriers to reporting exist for adults as well, as when a child discloses sexual abuse to them or they suspect that child sexual abuse may have occurred. For example, adults may not know what to do or who to call for help or may feel they have to prove the abuse happened before they report it (NSVRC, 2012b). They may worry that it is none of their business or that they will make things worse by reporting (NSVRC, 2012b). They may worry about consequences they may experience if they make a report on behalf of a child, such as loss of friendships, a job, or social status (NSVRC, 2012b). Victims’ family members may also be hesitant to report due to the stigma associated with sexual victimization and fear of legal action against perpetrators who might be family members or friends (Almeida et al., 2008).
When children do disclose sexual abuse, the disclosure itself is often part of a process rather than one event (Allnock, 2010; Flam & Haugstvedt, 2013; Schaeffer, Leventhal, & Asnes, 2011). Sexual abuse is not typically disclosed to or suspected by others immediately following the abuse (McElvaney, 2015). A disclosure may be initiated, whether accidentally or purposefully, following a change in the child’s behavior or a physical complaint (for example, pain when washing the genital area or a bloodstain in diapers or underwear) (WHO, 2003). (See B3. Entry into the Health Care System for more on related signs and symptoms.)
Children may first “test the waters” to see how adults react to hints about sexual abuse—if they react with anger, blame, or other negative responses, the child may stop talking or later deny the abuse (IRC, 2012). Children may also only partially disclose, telling just enough about the abuse to initiate a response that will end further abuse. This manner of delayed and drawn-out disclosure can have implications for agencies and professionals involved in the initial response to child sexual abuse, as well as for examination and investigative approaches. For example, child sexual abuse medical forensic examinations usually require interpretation of physical findings that may be healed injuries, rather than injuries seen following a recent sexual abuse (Arkansas Commission on Child Abuse, Rape, and Domestic Violence, 2014). The examiner must be able to distinguish normal genital variations and changes as children grow from evidence of healed injuries of sexual abuse (Arkansas Commission on Child Abuse, Rape, and Domestic Violence, 2014).
Prepubescent children who experience sexual abuse can suffer from a wide range of health problems across their lifespan. In addition to immediate health issues, such as sexually transmitted diseases (STDs), physical injuries, and psychological trauma, child sexual abuse victims are at greater risk for a plethora of adverse psychological and somatic problems into adulthood in contrast to those who were not sexually abused (Jenny et al., 2013; Springer et al., 2003). Health problems can include but are not limited to those below.
Examples of Health Problems Associated with Child Sexual Abuse (not inclusive)
Every child is different in how they are affected by sexual abuse. A variety of factors can impact the severity of their reactions. Factors fall broadly into the following categories (WCSAP, 2009):
- The child’s previous experiences and history of trauma (with more trauma and adverse life experiences, such as chronic abuse and polyvictimization, likely increasing the risk of serious problems from the sexual abuse);
- The nature of the sexual abuse and the child’s reactions during the abuse (the potential for negative impact may be greater in certain situations—for instance, when the child believed she/he was in extreme danger or the abuse was her/his fault, when the abuse occurred over time and the child lived with ongoing fear and worry about being abused, and when the child was abused by someone who was important to her/him); and
- What happens after the sexual abuse, especially how caregivers respond (e.g., in a way that is validating and supportive of the child versus not believing the child, minimizing what happened, or making the child feel guilty for not disclosing sooner or for disrupting the family) and the child’s perception of what occurred.
With appropriate support and resources, children can heal from sexual abuse. From a health perspective, the medical forensic exam process provides a proactive vehicle for communities to:
- assess sexually abused children’s health status and identify health concerns of children and their caregivers;
- provide emotional support for children and their caregivers as well as education so they are aware of their options and available resources for treatment and healing;
- coordinate treatment for physical, psychological, and behavioral issues; and
- develop a plan to promote healing that minimizes and mitigates the negative health outcomes for children over time.
Justice system agencies can also help facilitating healing for children in these cases by addressing their safety needs and connecting them and their families with related justice system services.
Mental health treatment can play an integral role in reducing children’s trauma symptoms. Ongoing support from victim advocacy programs can promote children’s healing, while assisting children and their caregivers with planning for physical and emotional safety. A range of additional services specific to child and family needs can contribute to children’s wellbeing. All involved in the community response to child sexual abuse can build upon children’s resiliencies—their ability to maintain or recover wellbeing despite adversity—to help them cope with their reactions (adapted from IRC, 2012).
Family issues are complicated. Caregivers and other family members often play a primary supporting role for prepubescent children during reporting, initial community response, the exam process, and beyond (whereas adult and adolescent victims may also or instead turn to friends and intimate partners for support after sexual victimization). Caregivers in particular need to be educated on how to provide support and protection to prepubescent children while facilitating their healing over time. In addition to verbal education on these matters, it can be helpful to provide caregivers with related written materials during and at the conclusion of the exam process. They also may benefit from ongoing help to cope with the impact of the child’s victimization on their own lives (e.g., they may react by feeling self-blame and guilt for not preventing the abuse or believing a child’s disclosure, or, if the perpetrator is their family’s main source of income, they may be stressed by the financial implications of loss of that income). Some caregivers may have their own trauma histories that may or may not have been previously addressed. They may experience PTSD from their own victimization, which can impact their ability to facilitate their child’s healing. They may require support to be able to move towards healing themselves and to assist their children.
If the caregiver or another family member accompanying the child during the exam process is the perpetrator or is in collusion with the perpetrator, or is otherwise abusive to the child, an issue of paramount importance is protecting the child during the examination and after. It is also critical to identify and protect any potential contact children. It can be complicated to help children move towards healing when perpetrators are caregivers or family members, especially if other family members are torn about whom to believe or are in denial that someone they care about would engage in such an act (WSCAP, 2009).
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 This protocol focuses on examinations for victims, not suspects. However, note that in the case of prepubescent children who display problem sexualized behaviors, examinations should be done by health care providers as these children may also be victims of sexual abuse. See Cavanagh Johnson (2009) for one resource on helping children with problem sexual behavior.
 Note that the U.S. justice response to child sexual abuse encompasses two systems—criminal justice, which deals with crimes, and child protection, which deals with civil legal issues related to child abuse and neglect (adapted from Finkelor, Cross, & Cantor, 2005). This protocol speaks to how these systems must coordinate their initial interventions when disclosures or suspicions of child sexual abuse are reported, as well as work collaboratively with agencies outside the justice system to facilitate medical forensic care for children and psychosocial support for children and their families to promote healing.
 Existing guidelines related to the clinical management of suspected child sexual abuse generally recommend that all child victims undergo a medical forensic examination (Adams et al., 2015; Finkel, 2011; De Jong, 2011; Walsh et al., 2007).
 This bullet is adapted in part from the International Rescue Committee [IRC] (2012), Washington Coalition of Sexual Assault Programs [WCSAP] (2009), and Day and Pierce-Weeks (2013). The information related to parental/guardian responsibilities was drawn from FindLaw (2015) at http://family.findlaw.com/guardianship/guardianship-of-minors.html.
 Child development refers to how children become able to do more complex things as they get older, with a focus on gross and fine motor, language, cognitive, and social skills (University of Michigan Health System, 2015). In addition to physical growth, children typically experience distinct periods of development as they age. For information on developmental milestones, see the Center for Disease Control and Prevention (CDC) (2015c) at www.cdc.gov/ncbddd/childdevelopment/facts.html.
 The onset of puberty should not be correlated to a chronological age; however, concerns about precocious or delayed sexual development should be referred to the appropriate pediatric specialist.
 Note that the scale was developed with reference to a single ethnic group and a relatively small sample of only 200 children (Blackemore, Burnet, & Dahl, 2010). Care should be taken to assess children for pubertal development based on a knowledge of local ethnic variations in breast development, pubic hair growth, distribution, or growth patterns and common characteristics.
 Standardization of medical processes is intended to reduce variability, improve care, reduce mortality and morbidity, and decrease costs (Adams et al., 2015).
 It can also be a useful reference for entities that are required to comply with legislation involving immediate response to child sexual abuse victims. For example, for juvenile detention center administrators striving to comply with the Prison Rape Elimination Act (PREA), the protocol can help them customize a standardized response to sexual abuse of prepubescent children housed in their facility (noting it is rare for young children to be in juvenile detention). The Introduction and Chapters A1 through A3, in particular, offer these administrators insights on victim care and coordinated response issues specific to this population.
 Also the CDC (2015a) at www.cdc.gov/violenceprevention/childabuseandneglect/riskprotectivefactors.html offers information on factors that contribute to the risk of child abuse and neglect, as well as protective factors that buffer children from that risk.
 The list was drawn in part from the Ohio Chapter of the American Academy of Pediatrics (AAP) Committee on Child Abuse and Neglect (2009).
 Drawn from 18 U.S.C. § 2246. See Offices of the U.S. Attorneys. (n.d.).
 See the National Children’s Advocacy Center’s Child Abuse Library Online (CALiO) at http://calio.org/resources/trafficking-and-commercial-sexual-exploitation-of-minors for information and links to resources on commercial sexual exploitation of children.
 See CALiO at http://calio.org/resources/drug-endangered-children-resources for resources on drug-endangered children.
 This definition emphasizes different kinds of victimization, rather than just multiple episodes of the same kind of victimization (Finkelor, 2011). See CALiO at http://calio.org/resources/poly-victimization for more resources on polyvictimization.
 Note there may be instances where individuals are coerced to sexually abuse a child (e.g., in a domestic violence scenario).
 Genital mutilation involves partial or total removal of the external genitalia or other injury to the genital organs, whether for cultural or other nontherapeutic reasons. See WHO (2014) and WHO and the Joint United Nations Program on HIV/AIDS (2007).
 See WHO (2013) for information on child marriage.
 Be aware of differences among terms: SEX refers to the sex designation that a person was assigned at birth, generally determined by genitalia and/or reproductive anatomy. Sex may also be inferred by someone’s secondary sex characteristics or chromosomes. GENDER refers to the attitudes, feelings, and behaviors that a given culture associates with a person’s biological sex. Individuals may or may not adhere to societal expectations associated with their presumed gender, which often only includes two genders (male and female). GENDER IDENTITY refers to an individual’s internal sense of being male, female, or another gender (not necessarily visible to others). INTERSEX refers to a variety of conditions in which a person is born with reproductive anatomy that does not fit the typical definitions of female or male, or has chromosomal structures other than just XX or XY. TRANSGENDER is often used as an umbrella term to encompass a wide range of people whose gender identity or expression may not match the sex they were assigned at birth. SEXUAL ORIENTATION refers to whether someone is primarily attracted to people of the same gender (lesbian or gay) or the opposite gender (heterosexual), or attracted to more than one gender (bisexual). This information was drawn from the National Sexual Violence Resource Center [NSVRC] and Pennsylvania Coalition Against Rape (2012) at www.nsvrc.org/sites/default/files/Publications_NSVRC_Guides_Talking-Gender-Sexuality.pdf, National Child Traumatic Stress Network (2014) at www.nctsn.org/sites/default/files/assets/pdfs/lgbtq_tipsheet_for_professionals.pdf, and personal communications with M. Munson, November 2015. Also see FORGE (2012) at http://forge-forward.org/wp-content/docs/FAQ-05-2012-trans101.pdf. A related note: Although this document sometimes uses he/him/his and she/her/hers pronouns, a growing number of people are using gender neutral or alternative pronouns such as ze, xe, and the singular they. Similarly, many individuals may use a name and pronoun that is different than their identification or insurance documents. The protocol recommends that responders ask children what name and pronoun they prefer. For more information on this topic, see FORGE (2015) at http://forge-forward.org/wp-content/docs/FAQ-Pronouns.pdf.
 It is important that responders are aware and can explain to children and caregivers (adapted from Male Survivor, n.d.; 1in6.org, n.d.): Sexual abuse is about taking advantage of a child’s vulnerability; it is not caused by the sex, sexual orientation, or gender identity of the perpetrator. Sexual abuse cannot determine a victim’s sexual orientation and gender identify. Even if the child liked the attention she/he received or was sexually aroused during the sexual abuse, these reactions do not indicate the child’s sexual orientation or gender identity. This issue can also be explored post-exam, particularly in victim advocacy and mental health settings.
 The National Children’s Advocacy Center (2015) at http://calio.org/images/grooming-bib2.pdf offers a bibliography of articles on perpetrator manipulation of child victims.
 See Smith and Harrell (2013) for a discussion on sexual abuse of children with disabilities. Children with disabilities are three times more likely than children without disabilities to be victims of sexual abuse (Lund & Vaughn-Jensen, 2012; Smith & Harrell, 2013). The likelihood is even higher for children with certain types of disabilities, such as intellectual or mental health disabilities (Lund & Vaughn-Jensen, 2012; Smith & Harrell, 2013).
 This list was adapted primarily from IRC (2012) and NSVRC (2012b). Also see Schaeffer, Leventhal, and Asnes (2011).
 Campbell et al. (2013) found that adolescent victims with voluntary disclosure patterns were more likely to remain engaged with the legal system throughout the investigation process than those with involuntary disclosure patterns. Different dynamics contribute to whether, when, and how prepubescent children disclose sexual abuse compared to adolescents. However, this study has application in that it emphasizes considering which disclosure patterns and help-seeking activities of child victims and their caregivers may correlate with their engagement in the medical and legal systems.
 Although the term sexually transmitted disease (STD) is used in this protocol, STDs are also commonly and correctly referred to as sexually transmitted infections (STIs). (See Glossary and Acronyms.)
 This list was adapted in part from Day and Pierce-Weeks (2013); Jenny, Crawford-Jakubiak, and the Committee on Child Abuse and Neglect (2013); Springer et al. (2003); and OVW (2014). Also see the CDC (2014a).
 The following overview was drawn from the National Institute of Mental Health (n.d.): PTSD is an anxiety disorder that develops for some people after seeing or experiencing a dangerous event. PTSD symptoms can be grouped into: (1) re-experiencing symptoms, such as flashbacks (reliving the trauma over and over); bad dreams; and frightening thoughts; (2) avoidance symptoms, such as staying away from places, events, or objects that are reminders of the experience; feeling emotionally numb; feeling strong guilt, depression, or worry; losing interest in activities that were enjoyable in the past; and having trouble remembering the dangerous event; and (3) hyperarousal symptoms, including being easily startled, feeling tense or “on edge,” and having difficulty sleeping and or having angry outbursts. For very young children, PTSD symptoms may include bedwetting, forgetting how or being unable to talk, acting out the scary event during play, and/or being unusually clingy with caregivers or other adults. Although some of these symptoms naturally persist after a traumatic event, when symptoms last more than a few weeks and become ongoing, they may suggest PTSD. The National Center for PTSD (2015) noted that children who experience prolonged, repeated sexual victimization and other trauma may have additional symptoms indicative of more severe psychological harm (sometimes referred to as complex PTSD)—they may have problems with emotional regulation, dissociation, self-perception, and perception of the perpetrator and relationships with others, and experience a profound sense of hopelessness and despair. The Welfare Information Gateway (2015) at www.childwelfare.gov/pubs/issue-briefs/brain-development/ offers a brief on the effects of child maltreatment on brain development.
 The following are examples of supporting literature: suicide attempts (Devries et al., 2014; Chen et al., 2010; Pérez-Fuentes et al., 2013); depression (Bebbington et al., 2011; Coles et al., 2015; Danielson et al., 2010), anxiety (Chen et al., 2010; Simon et al., 2009); low self-esteem (Coles et al., 2015); PTSD symptoms (Barrera, Calderón, & Bell, 2013; Chen et al., 2010; Danielson et al., 2010); conduct disorders/delinquency (Danielson et al., 2010; Maniglio, 2015); unsafe sexual behaviors (Jones et al., 2013; Mosack et al., 2010); substance use, addiction, and abuse (Balsam et al., 2011; Danielson et al., 2010; Khoury et al., 2010; Najdowski & Ullman, 2009; Topitzes et al., 2010); eating disorders (Chen et al., 2010; Doshi & Grossman, 2012; Sanci et al., 2008); obesity (Midei, 2011; Rohde et al., 2008); chronic pain (Coles et al., 2015); STDs (Jewkes, Sen, & Garcia-Moreno, 2002), including human immunodeficiency virus (HIV) (Jones et al., 2010; Mosack et al., 2010); overall poor health (Coles et al., 2015); sexual and intimate partner violence victimization (Balsam, et al., 2011; Black et al., 2011; Lalor & McElvaney, 2010; Messman-Moore et al., 2010); and sexual dysfunction (Straples, Rellini, & Roberts, 2012; Swaby & Morgan, 2009). In addition, Jones et al. (2013) found that child sexual abuse victims may internalize the trauma (e.g., by withdrawing, becoming anxious or depressed, and complaining of bodily health problems) or externalize the trauma (e.g., by having attention-deficit problems, engaging in aggressive behaviors, and breaking rules). Victims who exhibited externalized behaviors were at increased risk of engaging in sexual intercourse before the age of 15, having multiple partners, and not using protection during sex.
 See CrimeSolutions.gov (n.d.) at www.crimesolutions.gov/PracticeDetails.aspx?ID=45 for a discussion of therapeutic approaches for sexually abused children and their families, based on review of several meta-analysis studies. Also see the National Crime Victims Research and Treatment Center’s Child Physical and Sexual Abuse: Guidelines for Treatment (Saunders, Berliner, & Hanson, 2003) at https://mainweb-v.musc.edu/vawprevention/general/saunders.pdf. In addition, the Child Welfare Information Gateway at www.childwelfare.gov/topics/responding/trauma/treatment/ offers links to resources on the treatment programs to meet the needs of children, youth, and families affected by trauma.