A4. Health Care Infrastructure
This section discusses the local health care infrastructure essential to conducting the sexual abuse medical forensic examination for prepubescent children:
- Pediatric examiners;
- Health care facilities; and
- Equipment and supplies.
This infrastructure should be built on the recognition that child sexual abuse is a serious health problem, in addition to a child protection and criminal justice issue, and that the local health care system plays a crucial role in caring for prepubescent children who have been sexually abused. This infrastructure must be built on the knowledge that local response to child sexual abuse is complex and multifaceted, requiring the health care system to be part of a multidisciplinary coordinated effort. (See A3. Coordinated Team Approach)
Pediatric examiners’ presence in a community and their participation on the multidisciplinary response team depends to a large extent upon the capacity and/or commitment of the local health care system(s) to provide a high-quality response to child sexual abuse. Implementation of such a response includes but is not limited to: supporting specialized education of medical providers in the evaluation of child sexual abuse; hiring trained examiners; implementing comprehensive examination protocols; promoting feedback methods on examiner performance, including a system of peer review; and supporting continuing education and networking for examiners (Green, 2013; Meunier-Sham, Cross, & Zuniga, 2013; West Virginia Children Advocacy Network, 2014).
Although it may not be feasible for every health care facility in a community to offer specialized care for this population, every community should make available:
- Pediatric examiners who provide this specialized care as part of a multidisciplinary team response; and
- Health care facilities in which pediatric examiners conduct acute and nonacute examinations and where optimal access is offered to the full range of medical services that child victims may require (for acute care).
Every health care facility in a community—but particularly in pediatric primary care settings and hospital emergency departments—needs the expertise to initially assess children who present with sexual abuse to determine the urgency of medical forensic care needed, and arrange for the appropriate care. (See B3. Entry into the Health Care System)
A4a. Pediatric Examiners
These recommendations are for communities and health care systems related to pediatric examiners. For recommendations related to health care providers involved in initial response prior to the medical forensic examination, see B3. Entry into the Health Care System.
Every community should have ready access to trained, competent pediatric examiners who can provide medical forensic care to prepubescent children who disclose sexual abuse or are suspected of being sexually abused. (Ready access means that the community has designated pediatric examiners to respond to requests to perform examinations within prescribed time frames for acute and nonacute cases. For example, a community might require examiners to respond within 60 minutes to requests for acute care. Response times for nonacute care typically are more flexible) Communities across the country rely on a range of health care providers (e.g., physicians, advanced practice nurses and physician assistants, and registered nurses) who have been specially educated and have completed training requirements to perform this examination for a pediatric population.
Key Roles and Responsibilities of Pediatric Examiners: Prepubescent Children
As much as possible, pediatric examiners should be on permanent rather than temporary assignment in a community. However, as health care staffing challenges exist across the country, facilities often rely on temporary staffing. It can be difficult for temporary health care staff to understand the needs of child sexual abuse victims in their assigned community or to be familiar with related facility/jurisdictional policies and procedures. Also, if staff move to another assignment, arranging court testimony can be complicated. Facilities should have policies in place to address these issues.
Support advanced education, supervised clinical practice, and certification for health care providers who conduct medical forensic examinations for prepubescent child sexual abuse victims. It is critical that health care providers are afforded sufficient time by their health care facilities to pursue these opportunities. It is also important to recognize that specific education, practice, and supervision needs may vary across involved disciplines and jurisdictions. For example, non-physician examiners in a specific state may require medical supervision and backup in addition to completing necessary training and clinical requirements.
Pediatric examiner certification through the IAFN is available to registered nurses and advanced practice nurses trained as sexual assault nurse examiners (SANEs). Pediatricians can seek child abuse certification through the AAP. NCA standards for accredited children’s advocacy centers set minimum guidelines for health care providers who conduct child abuse medical evaluation through accredited children’s advocacy centers. States and communities may also have their own criteria for pediatric examiner education and clinical practice.
To support the above initiatives, communities and health care systems can encourage the following:
- The development of educational programs for pediatric examiners of all disciplines (both discipline-specific and across disciplines where appropriate);
- Provision of education in medical schools, nursing schools, nurse practitioner programs, and physician assistant programs on the general topic of child sexual abuse, with the goal of more effective medical screening and appropriate intervention if child sexual abuse is disclosed or suspected; and
- Strategic planning on how to systematically train, secure, supervise, and retain pediatric examiners to serve poor, rural, or remote areas, tribal communities, migrant farm worker communities, military installations, and other areas needing an enhanced response to child sexual abuse.
Support the ongoing education of pediatric examiners, as well as their access to experts in the child sexual abuse field who can participate in examiner training, mentoring, proctoring, peer review of medical forensic examinations, and quality assurance. Access to experts and ongoing education has been shown to increase examiner competence and improve the quality of examinations, documentation, and interpretation of findings over time (Adams et al., 2015). In addition, examiner participation in multidisciplinary training opportunities and case review can help evaluate and improve team response and interventions. (See A3. Coordinated Team Approach)
Note that for purposes of tracking down examiners who have moved, most hospitals or medical clinics by which physicians or advanced practice providers are employed or affiliated require them to apply for facility privileges. Providers requesting privileges usually must agree to submit forwarding addresses when they leave. Also, medical licenses can be tracked to the state or territory where the provider is working.
Support pediatric examiners in establishing peer review processes. In peer review, medical experts in child sexual abuse across disciplines have the opportunity to review written and photographic documentation of a child’s examination. They may discuss interpretation of medical findings—particularly those thought to be abnormal or indicative of sexual abuse—and give the provider who conducted the examination input on his/her care and documentation (Adams et al., 2015; Midwestern Children’s Advocacy Center, n.d.). Attention to cultural issues may also be discussed. Peer review has been demonstrated to improve professional practice patterns (Greeley et al., 2014). It can help to improve diagnostic accuracy, assist with confirmation and verification of exam findings, and establish a consensus in the data and interpretations (Morton et al., 2010). Because often no residual visible injury is seen in child sexual abuse cases, the use of peer review can be particularly helpful in strengthening examiners’ skills to not overcall a normal variant finding as consistent with sexual abuse (Adams et al., 2015; Makoroff et al., 2002).
The reasons that examiner programs conduct peer review differ from jurisdiction to jurisdiction. Some programs use it as a quality assurance process, while others use it as ongoing education for providers (Rotolo & Gorham, n.d.). Each program should have a peer review process that is clearly defined, including a rationale for conducting the review.
Encourage continued research and pilot projects related to telehealth practices in child sexual abuse medical forensic examinations. Some jurisdictions, particularly those in rural and remote areas, are taking advantage of a range of advanced technology to support examiners who conduct medical forensic examinations. Use of such technology in health care (sometimes called telehealth or telemedicine) can potentially allow pediatric examiners to mitigate the barriers of geography to consult with offsite medical experts.  Pediatric examiners’ most common uses of telehealth strategies are in peer reviews, seeking an expert opinion, and education. Note that many national-level organizations that provide training and technical assistance of interest to pediatric examiners use technology strategies to extend their services to the widest possible audience.
An emerging practice is telehealth as a tool to help guide clinicians in real-time patient encounters through live expert consultation. Before live remote consultation during medical forensic examinations of prepubescent child sexual abuse victims can become more widely accepted, there are a range of logistical and ethical issues and concerns to be considered, practices to be evaluated, guidelines and professional education to be developed. A few of the related issues that need to be explored are:
- The need for experts’ licensure in the state in which the consultation is being provided;
- The need for liability insurance for experts;
- Practices regarding who covers costs of expert consultation;
- Experts’ participation in potential criminal and civil justice proceedings;
- Impact of telehealth strategies on case prosecution;
- The possibility that the video consultation could become part of case evidence (recognizing that consultation is part of any criminal, civil, or family court proceedings);
- Procedures for protecting patient privacy and complying with applicable privacy laws;
- Logistics of child-focused, victim-centered, trauma-informed care using telehealth strategies; and
- Concerns about telehealth strategies being viewed as a budget-cutting tool that could lead to the elimination of local examiners (recognizing that a trained pediatric examiner on-site is the best practice).
These recommendations are for communities to build the capacity of local health care systems to respond to sexual abuse of prepubescent children.
Recognize the obligation of health care facilities to serve prepubescent patients who have experienced sexual abuse.
- Although not every health care facility in a community has the capacity to offer pediatric medical forensic examinations, every community should designate health care facilities that can provide this specialty care (within a reasonable travel distance for children and their families, with the term reasonable locally defined). The medical forensic examination of prepubescent child sexual abuse victims should occur at a medical site where trained pediatric examiners conduct the examination. Acute and nonacute care may be offered at the same or different facilities, but both types of examinations need to be readily available to the local population. (Examinations that are readily available are offered within a prescribed time frame appropriate for the urgency of care needed and within a reasonable travel distance for children and their families) For acute care, the exam site should also have easy access to a full range of medical services that may be required by these children.
- All health care facilities, but especially primary care settings and hospital emergency departments, should screen for child sexual abuse. If sexual abuse is disclosed or suspected, care providers should be aware of community response policies and implement community-specific interventions for initial health assessment (note this initial assessment is NOT the medical forensic examination). Primary care and emergency department medical personnel should: (1) ensure that child victims who enter the health care system receive necessary emergency medical treatment and are assessed for urgency of medical forensic care needed; (2) make a mandatory report of the sexual abuse to legal authorities; and (3) arrange medical forensic care performed by a pediatric examiner. (See B3. Entry into the Health Care System)
Facilities should be familiar with the federal Emergency Medical Treatment and Active Labor Act (EMTALA), which has provisions pertaining to the ability of hospitals to transfer patients with emergency medical conditions.
Explore possibilities for optimal exam site locations. Multidisciplinary response teams for child sexual abuse, in conjunction with health care facilities and pediatric examiners, should determine where acute and nonacute examinations for prepubescent children should be conducted for their community.
Key Factors to Consider when Identifying Designated Exam Facilities
Consider what type of system of designated exam facilities best serves community needs (e.g., local, tribal, regional, state, territorial, or other). Some issues that might affect this decision include: type of community demographics and geography; availability of health care facilities and specialized care programs; capacity to secure trained pediatric examiners and necessary space, equipment, and supplies; and willingness of involved disciplines to coordinate with particular facilities. Multidisciplinary response teams are encouraged to consider first using nearby facilities so that children and families do not have to travel considerable distances for care. Military installations may rely on military health facilities if they have access to a trained pediatric examiner. However, some communities may opt for regional rather than local facilities. For example, a small state, a tribe, or a sparsely populated region may establish one or more designated facilities to serve all of its localities.
Consider a model of medical service provision for child victims of sexual abuse in which the initial assessment of urgency of care needed, the medical forensic examination, and related health care are provided to children in the same location and preferably by the same health care provider (a trained pediatric examiner). The exception would be if the child required emergency medical care—hospital emergency department personnel typically will attend to those needs first.
If a transfer of the child from one health care facility to a designated acute exam site is necessary, use procedures that address children’s needs, satisfy EMTALA requirements, and minimize time delays and loss of forensic evidence. Communities and health care facilities should avoid transfers whenever possible, as it can cause children and family members further stress, and destroy forensic evidence. However, if a child arrives at a health care facility within the jurisdictional time frame for acute medical forensic care or such care is otherwise indicated (see B3. Entry into the Health Care System) and the facility is not able to provide that specialty care, interagency transfer procedures must be in place to transfer the child to the nearest designated acute exam facility. The initial facility should communicate with the receiving exam site to confirm the availability of a pediatric examiner to provide care to ensure minimal or no delay in the medical forensic examination process. The child should receive a general medical screening promptly after arrival at the initial facility (e.g., within one hour)  and before transfer to another health care facility. Emergent medical injuries or psychological issues must be addressed before initiating a transfer.
Prior to the transfer, providers should discuss with the child and caregiver the reasons for the transfer. Health care providers can work with criminal justice representatives and advocates to ensure related transportation needs are met and other support needs of the family are addressed (e.g., child care for other children). Support and advocacy at the initial facility and exam site should be offered when available.
When making a transfer, health care facilities should prioritize the child’s comfort and take precautions to minimize the loss of forensic evidence. A copy of the child’s records, including reports of any treatment administered or testing performed, should be transported with the child to the exam facility.
Develop agreements among responders to clarify facility issues. Communities should consider:
- Agreements among health care facilities regarding standard practices in screening for and responding to suspected prepubescent child sexual abuse . Such an agreement should address expectations related to: screening, mandatory reporting, addressing child safety issues, emergency medical care, initial assessment for urgency of care needed, arranging specialized care, backup planning (e.g., in the case a pediatric examiner is not available at the exam site or multiple victims require care beyond what one site can manage); and transfer procedures from one health facility to an exam site, if necessary.
- Agreements among health care facilities, exam sites, children’s advocacy centers, investigative agencies, and multidisciplinary response teams regarding the logistics of designated exam sites . Such an agreement should identify designated exam sites and whether they provide acute and/or nonacute examinations, primary exam sites and alternatives, hours of operation for each site, procedures for facilitating an examination at each site, and referrals to community resources.
- Agreements among health care facilities, exam sites, multidisciplinary response teams, children’s advocacy centers, and community-based sexual assault victim advocacy programs to ensure victim advocacy . Procedures are needed to allow activation of victim advocates trained to work with children (if available) to come to the exam site or another health care facility to which children may present and to provide crisis intervention, advocacy, and accompaniment services for children, caregivers, and/or other family members. This agreement can clarify the potential roles of victim advocates in the exam process, coordination of services, and confidentiality issues.
A4c. Equipment and Supplies
These recommendations are for health care facilities and pediatric examiners for exam equipment and supplies.
Plan to have specific equipment and supplies readily available for the medical forensic examination of prepubescent victims of sexual abuse. Below is a checklist of equipment and supplies, with minimum requirements starred (*) (adapted in part from Day & Pierce-Weeks, 2013). However, follow jurisdictional and facility policies regarding use of specific equipment and supplies. Note that not every item will be needed in every case.
Checklist of Equipment and Supplies
❒ Examination table/bed/stretcher (consider access issues for children with physical disabilities)*
❒ Patient gowns and bed linens/sheets
❒ Basic medical supplies for injury treatment (e.g., sutures, bandages, splints, and scissors)
❒ Resuscitation equipment
❒ Patient comfort supplies (See A1. Principles of Care)
❒ Powder-free, latex-free, nonsterile examination gloves*
❒ Culture supplies*
❒ Needles, syringes
❒ Sharps disposal container
❒ Method or device to sterilize equipment
❒ Sterile water, sterile normal saline*
❒ A method or device to dry specimens (e.g., swab dryer or open air cardboard drying rack)
❒ Forensic evidence collection kits, forms, and exam protocol* (See A5c. Evidentiary Kits and Forms)
❒ Any testing supplies not included in the forensic evidence collection kit (and access to testing results)
❒ Forensic supplies* (e.g., paper bags, evidence tape for sealing bags, additional envelopes, containers, cotton-tipped swabs, and packaging for wet forensic evidence) (See B8. Evidence Collection for other supplies)
❒ Handheld magnifying glass or magnified visor
❒ Digital camera and related supplies (e.g., batteries, flash, photographic reference ruler/standard—basic and color, identification stickers, tripod/monopod, camera manual, and cleaning supplies) (See B6. Photo-Documentation and B7. Examination)
❒ Scales, height chart, measuring tape
❒ Written materials for children and caregivers (See A1. Principles of Care)
Additional equipment and supplies to consider:
❒ A mobile cart or portable pack for the inpatient child
❒ An alternate light source (ALS) to aid in examining patients’ bodies, hair, and clothing. ALS can be used to scan for forensic evidence, such as dried or moist secretions and fluorescent fibers, which is not visible in ambient light (see B7. Examination)
❒ Toluidine blue dye (TBD) may be used to accentuate minor epithelial damage, either with or without magnification (see B7. Examination) 
Examiners should know how to properly use all related equipment and supplies, specific to prepubescent children. It is important that pediatric examiners, exam facilities, and forensic scientists stay abreast of the latest research on equipment and supplies used in caring for prepubescent children, and the current forensic science recommendations for forensic evidence collection. (See B7. Examination and B8. Evidence Collection for more on the use of equipment and supplies)
|Table of Contents||A5. Infrastructure for Justice System Response During the Exam Process|
 Adapted from Day & Pierce-Weeks, 2013.
 For example, two studies cite benefits of telehealth strategies specific for child sexual abuse medical forensic examinations–see MacLoed et al. (2009) and Miyamoto et al. (2014). An Office of Victims of Crime-funded pilot project, the National Telehealth Nursing Center, is using telemedicine technology to provide expert consultation to clinicians caring for adult and adolescent sexual assault patients in remote and/or underserved regions of the country.
 There are two basic telehealth approaches (drawn from WHO, 2010): Store-and-forward, or asynchronous, strategies involve the exchange of pre-recorded data between two or more persons at different times. For example, pediatric examiners may use store-and-forward applications to obtain input on a case from a medical expert for peer review purposes or a second opinion. Real time, or synchronous, strategies require involved persons to be simultaneously present for immediate exchange of information, as in the case of live peer review. In both applications, information may be transmitted in a variety of media.
 Health care facilities must ensure that electronic communication concerning patient health information conforms to applicable privacy laws (e.g., the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH)). (See A5b. Confidentiality and Release of Information.)
 For example, the Midwest Regional Children’s Advocacy Center hosts medically-focused peer review groups (see www.mrcac.org/peer-review/). Its Midwest Regional Medical Academy offers myCasereview (anonymous case review). See www.mrcac.org/medical-academy/mycasereview/.
 Historically, response to child sexual abuse has been perceived as largely a criminal justice or child protection system responsibility. However, child sexual abuse is a public health issue that has negative long-term implications for victims, families, and communities, and requires specialty care for its victims.
 Joint Commission standards for accreditation (www.jointcommission.org/standards_information/standards.aspx) address a health care organization’s level of performance in specific areas—not just what it is capable of doing, but what it actually does. The standards set forth maximum achievable performance expectations for activities that affect quality of care.
 The paragraph was drawn in part from Bobak (1992) and Ledray (2001).
 42 U.S.C. § 1395dd. For more information on EMTALA, see www.emtala.com. It may be useful for sites to exemplify many of the Magnet model outcomes outlined by the American Nurses Credentialing Center (2011).
 Hospital labs generally do not do the type of toxicology testing required in a sexual abuse case.
 Free-standing health clinics that conduct the examination should have ready access to medications that may be needed in these cases, such as those for HIV non-occupational post-exposure prophylaxis, even without a clinic pharmacy.
 See www.childrenshospitals.org/Issues-and-Advocacy/Population-Health/Child-Abuse for the Children’s Hospital Association’s (2011) Defining the Children’s Hospital Role in Child Maltreatment (2nd ed.).
 Title II and Title III of the Americans with Disabilities Act (ADA) explains requirements for facilities in accommodating persons with disabilities (which may vary depending on the type of facility). Title II prohibits discrimination against persons with disabilities in all programs, activities, and services of public entities. Title III requires places of public accommodation to make reasonable modification in their policies, practices, and procedures to accommodate individuals with disabilities. See www.ada.gov for related ADA information and resources.
 These are popular symbols of pride for lesbian, gay, bisexual, transgender, and/or intersex (LGBTI) people.
 The general medical screening determines airway, breathing, and circulatory status. It does not include examination of genitalia or additional screening unless there is evidence of hemodynamic instability, psychiatric crisis, or acute medical complaint (such as genital bleeding). It includes only a minimal history to establish last point of contact and the identity of the suspected perpetrator, if known. An acknowledgement of risk factors for HIV and other STDs needs to be taken into account during and as part of transfer.
 For example, the ideal is an exam table with a hydraulic lift for children with mobility impairments. If not available, health care personnel must know how to assist patients with physical disabilities onto standard exam tables. If it is determined that a patient can only be examined on an exam table with a hydraulic lift, procedures should be in place to transport the patient, in acute cases, to a site with such a table with as little loss of forensic evidence as possible.
 Use of a colposcope is an option if a community can afford/access such equipment. Note that colposcopes are the standard in many communities for magnified visualization and photo-documentation of anogenital structure detail. In communities which do not have the ability to use colposcopes, many are opting for digital cameras as the next best alternative to achieve magnification and capture still- and video images that allow for a permanent record of the anogenital examination findings.
 Examiners should be educated about the advantages and limitations of using ALS in sexual abuse medical forensic examinations and receive instruction on its proper use to improve sensitivity and specificity when identifying stains (Eldredge, Huggins, & Pugh, 2011). (See general instructions offered in B7. Examination.) The Wood’s lamp is no longer recommended, as semen samples do not fluoresce on fabric or skin at wavelengths associated with this light source (Anderst, 2011; Eldredge, Huggins, & Pugh, 2011; Santucci, 1999). ALSs with wavelengths of 400 to 600 nanometers (nm) are effective in fluorescing semen particles; use of light sources with wavelengths around 450 nm is reported to have 83 percent accuracy in differentiating semen from other stains. Note ALS use in detecting stains on skin is limited (Wawryk & Odell, 2005). Continued research is needed on: the use of ALS as a tool in identifying and collecting forensic evidence; the sensitivity and specificity of various long wavelength lights on various skin types and at various time frames after application of stains; the role of time and normal “wear and tear” on stains; and the development of a system to distinguish semen from other stains (Eldredge, Huggins, & Pugh, 2011). Note no research base currently supports the use of ALS to accurately interpret subclinical bruising. In fact, Lombardi et al. (2015) found in a study of adults that more than half the time, positive fluorescence of a bruise was actually something other than a bruise.
 TBD binds to nucleated squamous cells in the deeper layers of epidermis and, when properly applied, will only stain areas with acute injuries or those that have been recently abraded of the top epithelial layer (Blackburn & Stokes, 2013). TBD is not universally used in adult, adolescent, or prepubescent child sexual assault/abuse medical forensic examinations and is considered controversial as a tool for detecting injury in some jurisdictions (e.g., it may be perceived by the court as changing the appearance of the tissue). No research is available (and would be useful) on the use and limitations of TBD, specifically with prepubescent child sexual abuse victim population. (See B7. Examination for general instruction for use of TBD.)