From the Experts: Rich Kaplan

For May's "From the Experts" article, Rich Kaplan, MSW, MD, FAAP--Medical Director of the Child Abuse Program at the University of Minnesota Medical Center, Associate Professor at the university's School of Medicine, and primary author of the forthcoming Medical Response to Child Sexual Abuse--has provided an abridged history of medical care for the possibly sexually abused child. Please enjoy.

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Medical Care for the Possibly Sexually Abused Child

Child sexual abuse has been with us since the dawn of time, but the medical community has been extremely slow to respond to it. Although Auguste Abroise Tardieu showed promising activity with his research in France during the later part of the 19th century, the American response came much later, slower, and in a more stuttering fashion. Henry Kempe wrote The Battered Child with colleagues in 1963 and gave the first general public address on child sexual abuse in 1978, 15 years later. The first text that actually addressed child sexual abuse was by Suzanne Sgroi in 1982. It wasn’t until the 1980s that the medical community really responded in an organized fashion to sexual assault in general and the pediatric community responded more specifically to child sexual abuse. This was in no small measure due to the cultural and political changes engendered by the women’s movement in US and Western culture.

Medical Providers as Investigators

The next stage, the medical response, really came with the advent of colposcopy in the evaluation of child sexual abuse. With this technology, medical providers got an entirely new view of the prepubertal and peri-pubertal hymen; through the end of the 20th century, the primary role for medical providers dealing with sexually abused children was the quest for anatomic evidence of sexual abuse. As the newly magnified hymen was inspected and described, the medical community teamed with investigators and prosecutors in attempts to identify and prosecute perpetrators and to protect young victims.

With the evolution of the Children’s Advocacy Centers movement, the relationship between medical care providers and a multidisciplinary team became reified and there was a clear sense that investigation was a central part of the medical role.

The Emergence of a Subspecialty and Reframing of the Pediatric Role

As the newly established pediatric subspecialty of Child Abuse Pediatrics evolved, the discussion concerning the pediatric role and the care of possible abuse victims followed suit. Child abuse pediatricians held a series of consensus meetings around the nation in an attempt to reframe and redefine the medical role with respect to child sexual abuse as the provision of medical care, not investigation. These consensus conferences lead to the elucidation of certain general principles that clearly moved the medical response to another level. These principles were articulated in an article called The Guidelines for Medical Care of Children who May Have been Sexually Abused, published in the Journal of Pediatric and Adolescent Gynecology, volume 20, issue 3, in June 2007. This article not only restated the current evidence-based classification system of physical findings, but also—perhaps most importantly—helped clarify the medical role in response to child sexual abuse. This effort aligned the medical care of these children with the medical care for all children.

The role of medical provider was demystified in these cases while it was basically made clear that the medical provider’s role is much more similar to other pediatric care than different. The Guidelines for Medical Care of Children who May Have been Sexually Abused articulated the necessity of medical input throughout the process to make sure that a child’s health needs were being met. They also conveyed the importance of the process’s being based on these health needs, not simply the need for investigation. That meant that beyond the so-called forensic interview, someone had to take a medical history to ensure there were no other related symptoms or difficulties that were not discovered during the forensic process. Noting that numbers of children who may be abuse victims are potentially medically underserved, the article also clearly states the role for a thorough medical history and physical evaluation of these children.

In addition to reclarifying the role of the provider, The Guidelines for Medical Care of Children who May Have been Sexually Abused expressed the need for both specialty training in the care for these patients and ongoing mentoring and activities of quality improvement. This article served also as the intellectual base for the recrafting of the medical standard that all children’s advocacy centers would need to meet in coming years to remain accredited by the National Children’s Alliance.

This shift does not change the fact that a multidisciplinary response is necessary on behalf of a possible victim to provide the best care, safety, and protection. It simply states clearly that part of that response needs to be true medical care, especially because of the intrinsic vulnerability of these children and the resultant medical complications of being victimized. Having the medical issues clarified will actually strengthen the multidisciplinary response as it more clearly defines the medical role within the multidisciplinary team.