The , persons outside x but a fair number are extra-farmhal, involving e family unit. Hence, the abuser can be a parent, 2 family friend, older sister, younger brother, baby-sitter, teacher, coach, or any other relative of the child or any stranger of any age or either sex. In fact, the someone they know and P eat majorit of children are abused by o ten trust. C&d sexual abuse also occurs among all segments of society; it is a ublic health issue that crosses all economic, social, racial, and ethnic fi oundaries. While this definition reflects the language of the law, each health professional - whether a physician, nurse practitioner, nurse, hospital social worker, or any other - should consult with law enforcement personnel to learn of any special provisions in the laws of his or her State. Section II. The Report While rape is included in definitions of sexual abuse it is also a major crime by itself. Hence, if a child is brought in and says that he or she has just been raped (or the person who brought the child sa s so), you should immediately contact the police, who will assess K t e situation and take charge of the case. Such reporting, of course, is the responsibility of any citizen with information about any major crime. A case of child sexual abuse may be a concern of man different agencies in the community: child protective services, fami y services, P law enforcement, civil `ustice (juvenile and family court), and criminal justice, as well as hea th care. Many cases of child sexual abuse may I eventually involve all these a these cases ma iI become, encies or systems. However complicated someone files a t ey usually be `n quite simply when fi rief Report, usually by telep a services and/or the police. one, to child protective , Every state and territory re i! uires all health professionals to re ort to state authorities "any know ed e of' or even "any suspicion o P ' child abuse and neglect, including c%l `Id sexual abuse. Many states specify the categories of health personnel who must report (e.g., nurses, dentists, osteo aths interns, etc.); others merely say "any person" must report. tate 8 i aws may also impose a penalty on anyone who has such knowledge or suspicion but does not report it. You would "have knowle 9 of' child sexual abuse, for example, if a parent or a social worker rings in a child for medical attention and tells you that the child was - or may have been - sexually abused. That's when ou "know" that sexual abuse of the child is, at the very least, a possi i ili B and that's what you must report. But what does "suspicion" mean. `In child sexual abuse, as in virtually every other 3 area of patient care, a professional person's own instinct, honed by experience day in and day out, gives rise to those ."suspicions" that are the basis of good clinical judgment. And such judgment is the first line of defense for every child who is abused. Here are some circumstances in which you should "suspect" child sexual abuse: * A parent brings in a child who shows signs of physical i in the genital area and is experiencing pain. When asked about t x `ury ese symptoms, the child offers a history which is not consistent with your own climcal findings (was rough-housing with friends, fell off playground equipment, etc.). But the clinical information and your own "mt feeZings" tell you otherwise: you suspect that the child may have been sexually abused. You must, therefore, report your suspicion to the child protective services agency. You don't know who may have sexually abused the child and you don't know where or when the abuse occurred. But as a health professional, you don't have to know. If, in our own best clinical judgment, you suspect the child has been a used, ii then you must report that suspicion to your local or state child protective services agency. * A caseworker brings in a child who shows no outward signs of injury or abuse, but is presented as "always not feeling quite right." The child is reticent and even sullen, avoids eye contact with both you and the parent, and cannot - or will not - tell you what or where the trouble is. As becomes fearful and hig d ou begin a routine physical exam, the child y stressed. When you begin to examine the F nital and anal areas, the child becomes violent and tries to break ee. (Some child victims may do just the opposite: flop back in a highly suggestive position of total surrender.) You may not know who abused the child, but it's not your respon- sibility to find out. If you suspect that the child is or has been the victim of sexual abuse and needs protection, that's reason enough for you to make a report. And, by law, you must. * A child shows up for his or her annual physical examination. In the course of your workup, you discover the child has a sexually transmitted disease, vaginitis or urinary tract symptoms., or other signs and symptoms that raise serious suspicions of possible sexual abuse. Again, you are obliged to report your suspicions to the local or state child protective services agency. But what if you're wrong ? What if, in any one of these cases, the child had not been abused and, therefore, your suspicions cannot be substantiated? 4 All state laws recognize this concern and provide immunity for anyone who reports in a suspected case of chil P faith. A health professional who reports sexual abuse that is later shown not to have occurred, is protected by a "cloak of immunity" from any civil or criminal liability that might arise because of the report and subsequent events. The reverse, however, is not true. For exam who doesn't report a suspected case of chil ff le, a health professional abuse that actually did occur, has no "cloak of immunit ' the victim's family or B and can be sued for malpractice b rosecute R b A: number of such cases ave indeed the state for failing to report. L? en brought -- and won -- against health professionals in the last few years. Clearly the wisest and safest choice is to obey the law and report. But when should you make your report? How? And to whom? Most laws and guidelines advise you to report "in a timely fashion." That usually means immediately or, at the ve 7 least, within 24 hours. If a child is brou was sexually abused wit fl ht in by someone who al eges that the child `n the past few hours, you must report that information right away. If, during a physical examination for another roblem altogether you come across scarring or other physical Pi ndings of sexual abuse sometime in the past, you should report that information "in a timely fashion," also. An initial report is usually made by telephone. Most states also require a written follow-up report within 36 hours. Whether or not you file a written report with the state, make a note for your own records of what you said, to whom you said it, and when. As a general rule, a person who files a prompt written report with as much detail as possible is less likely to be asked to tostif in civil court later on; the written report will generally speak or itself. P (However, you may still be required to appear in a criminal proceeding; for more on this, see Section V.) All reports should be made directly to the child rotective services of your own state. Some state offices have you ca 1 a "hot-line" or an P 800- number; others have you report to a local or regional represen- tative. Here again, it% important to know the specific requirements of the law in your own state. Should you call the police, also? Where state law re u$?iopul and crossreporting, then of course you should call ii However, in most jurisdictions, that decision is most often ma,de?y personnel in child rotective services. But if the child -- or you or anyone involved wi 91 the child -- is in some immediate danger, or if 5 the child has been raped or sodomized, then the police should be called right away. At some time early in the recess, you must tell the child's arent or guardian that dy ou either h ow or suspect that the child R as been sexually abuse and, under state law, you are knowledge or suspicion to the state office for chil uired to report such "8 protective services. It is important to say this in as calm and dispassionate a manner as possible, indicati to the parent that you must take this action since sexual abuse coul ex lain one or more sym tams presented by the 3 child. If you are on tR e staff of a health faci ity, P to cite its policy or you may also wish `deline in such matters. Virtually every hospital or clinic in t e country does have a protocol or a policy 8" requirin sexual a It its personnel to report any knowledge or suspicion of child use to the child protective services agency. But whether or not there is such a policy, reporting is by law a personal respon- sibility that cannot be transferred to an institution. Most public systems and processes are haunted by the possibility that, instead of receiving service, a person needin he1 will somehow "fall through the cracks.' To prevent this, it is a f R visa le to "cross-re- port" cases of child sexual abuse, when appropriate, For example, if a child is brought to you b a police officer, note that fact and the officeis badge number an cr precinct. After making your initial re ort to child B rotective services, make a second call to the precinct tl esk and con rm the information there, also. It's far better to file a redundant report than to risk having the child "lost" by any system of protection and care. Similarly, it's important to avoid making, or seeming to make, any accusations of child may be P ' t in your report. The person who brought you the t e abuser...or may be one of several abusers...or may be nothin of law of the kind. That determination, however, is the province en orcement and the courts. P Section III. Assessment: The History The assessment of a child victim of sexual abuse consists of the taking of a histo , a child who has followed by a physical examination. Interviewing Tee n sexually abused, however, is not the kind of history-taking that has been taught in most schools for the health professions. The prime objective is still, of course, to elicit enough information to make a diagnosis and determine a course of treatment. But there are other objectives as well: the information gathered during the patient 6 assessment will help the state take the most a propriate civil action to protect the child from further abuse; it may R elp the state initiate criminal action against the perpetrator of the abuse; and it can provide clues for social service personnel helping the child's family t through a Els t&ion, or gui t. P eriod of time suffused with pain, anger, fear, While clearly im ortant for your purposes of providin R f effective health care for t e child, your initial encounter ma B a so be the child's first indication that an adult is conceme about what ha chi ened and wants to help. Hence, during the interview some fir en will want to share a great deal of information about their family's social, legal, or other problems. From a health point of view, these are of marginal interest; if you pursue them, you risk contaminating the data in your assessment and substantially limitin its usefulness. In this respect as in all others, it is therefore essenti s that heal ou maintain as your primwy concern the physical and mental x of the child. If the interview is conducted soon after the abuse occurred, the child's recollection will be at its clearest, and the interviewer will be most alert to important signs and signals from the child. Carefully record verbatim any statements the child may make about the (alleged) abuser, since these statements are admissible in court. Some ex UCR" rts urge that this initial interview be videotaped, arguin that s a videotape eliminates the need for re-interviews, whit ii only compound the anguish of the child and the famil . But videotaping is generally used far less by health professionals x an by court, police, and protective services personnel, who frequently enter their videotaped interviews into court proceedings. No single differs a preach works best with every child. Each assessment actor ing to a child's developmental age and his or her place a within the family. Also, some sexually abused children may be too H oung to be interviewed or too disturbed to give a coherent medical `story. In those instances, the answers must instead come from the child's parent or guardian suspected abuser). (assuming this person is not, in fact, the It is sometimes advisable for health professionals to have someone present from child protective services and, if possible law enforce- ment present during the interview. This is especiall helpful if you suspect that the child being interviewed was sexu s ly abused in a grou posse * ity Ll setting, such as a pre-school or day care center, raising the that other children are still at risk. Dealing with such a possibility is a task for persons other than health professionals. 7 The following pointers on conductin applicable, are particular1 an interview, while generally T useful wit children age three and above 5l who may have been sexua ly abused: 0 Make sure the child is comfortable. If you show impatience and other signs of not caring, you may be identified in the child's mind with the abuser...and the assessment will go badly, If it appears possible that a family member may be the krpetrator of the abuse insist on interviewing the child alone. send parents and other fan& members into another room to wait. `Later they can verify certain minimum items of fact (e.g., the child's fuli name, address, home telephone number, age, year in school, etc.). You may also note any statements they might make relative to the physical and mental health of the child. 0 Even though child has been sexua H ou may know - or strongly suspect - that the y abused, you should take great care to restrict ie our questions exclusively to the realm of the physical and mental alth of the child. Also, as in your initial report, be sure that you don't influence the interview so that it merely reinforces your own judgment as to whether or not the child was sexually abused. That determination will be made elsewhere through due process. 0 Note the child's use of an sexually provocative mannerisms directed toward you. This kind of earned behavior is often presented r by very voice an il oung sexually abused children. Note also the child's tone of , to the extent possible, write down verbatim any especially revealing remarks by the child. If you use anatomically correct dolls or line drawings ask Fhe child to name different body E arts breasts, genitals, and buttocks. A user's with specific attention t6 the frequently teach their young victims special names for these body parts; the names then become "their secret." These visual aids can also help a child explain what ha chi Yl ened. But here, also, you must be very careful not to "lead' the to focus on particular body parts and functions. 0 Ask the child about his or her physical, emotional, and mental health. But remember that each po&ble symptom of abuse is, by itself, of limited significance. This is precisely where good clinical judgment is so important. You must ask yourself: Is this or that symptom truly out of the ordinary, given this particular child, at this age, in this family, in this particular state of health? Ask about such symptoms as... trouble urinating (dysuria)...blood in the urine (hematuria)... involuntary urination, especially as bed-wetting (enuresis)...and any 8 pain, fever, discharge, or itching that may be related to urinary tract infections or genital lesions. abdominal pain...anorectal problems, such as itching bleeding and ain...fecal incontinence (encopresis)...and other evidence of bowel R abit dystunction. excessive masturbation...indications of sexual knowledge unusual or ina propriate P for a child that age...and sexual experience generally, inc uding knowledge of -- and experience with - oral, rectal, and/or vaginal penetration during prior abusive incidents. any rash or sores in the genital area...herpes or other sexually transmitted disease...and, for female patients, vaginal odor, pain, itching, bleeding, or unusual discharges. and, for adolescent patients in particular, ask about the frequency and severity of headaches...dramatic weight changes...trouble sleeping, includin school... ni htmares and other disturbances...serious problems in 8 % e a use of drugs and alcohol...depression . ..thoughts of - or attem ts P at - suicide...phobias of one kind or another...use of birth contra devices and medication...and pregnancy. If the interview is not going well, don't force it by askin questions; stop and get assistance from child protection or K leading ocal law enforcement personnel with more experience in these cases. Do not let your own eagerness, curiosity, sense of outrage, or any other personal feelings influence you to continue the interview along lines that he outside your own professional competence. After the history has been taken, go on to the physical examination of the child. Section IV. Assessment: The Physical Examination Every child who is or may have been a victim of sexual abuse must be given a hysical examination. If the most recent incident - known a -- occurred within the past 72 hours or if the child is in >~u%&ws clear evidence of injury you shodd examine the child immediately. Of the child has just be&n raped, however, you should contact the police ri ht away and obtain a commercial rape kit for the examination. T ait e great care in following the directions that are enclosed with the kit.) If speed is not of the essence, the child may then be examined by you at the earliest convenient time or referred elsewhere for that service. 9 If you feel you may lack sticient skill or experience to do a physical examination of a child for signs of sexual abuse, you may want to refer that child to a facility or a team with the requisite skills to handle the assignment, if one is local1 available. In any case, take a moment now to become familiar wi x local referral procedures; you might not have the time to do so later, when a potential child victim is in your office and in need of immediate help. Both the child and the parents or caretakers should be told about -- and prepared for - such an exam. All necessary permissions should be secured and the parents briefed on the kinds of lab tests that may be done, the the results wi R urpose of each (screening, diagnostic, forensic), when be available, and who will see them. This is also the time to alert parents to any financial assistance for which they might qualify, such as victim's compensation or other funds that cover medical and/or legal expenses. The physical exam should be done in the presence of someone the child can trust...a parent (if not the abuser) or a familiar nurse. Quietly explain what% going to happen and note the child's reaction. If the child was sexually abused within the past few hours, begin the exam, if possible by passing a Woods Lamp over the child's body and clothing. Seminal fluid shows up as a fluorescent dark een under a Woods Lamp. Obtain a specimen and have it checked or motile and $ non-motile sperm and for acid phos is not always accurate; hence, it's BP hatase. A Woods Lamp, however, so important to collect the child's c&thing in a paper bag for a more accurate examination by the police Many sexually abused children are also victims of other forms of physical abuse and neglect. Therefore, while a physical exam for signs of sexual abuse will necessarily center upon the urogenital and anon&al areas, it should be done as part of a complete physical exam. For example, sus icious child's le s, breasts, and \ marks might be detected on the such mar L uttocks during a quick overall h sical; are often caused by blows or restraints use 88 episodes of sexual abuse and they should be noted. uring Take special care to prepare the child for your examination of the anal and genital areas. A toddler may prefer to be examined while in its motheis lap; young children are most comfortable in the frog-leg r sition; older girls, however, should be examined in the customary ithotomy position. Gently spread the labia majora laterally and down, with some pressure against the perineum. This allows you to inspect each art of the genitalia (prepuce, labia minora, etc.). A magnifying co poscope is sometimes used to obtain a more precise P assessment of external trauma. If you suspect the presence of 10 internal vaginal injuries,. the examination may need to be done with the child under anesthesia. The most frequent signs of sexual abuse in the enital area of a female include bruises and lacerations; unusual re % ness of skin and tissue (erythema); bleeding and evidence of intradermal or submucosal hemorrhaging (the presence of petechiae); unusual changes in skin color or pigmentation; unusual discharges and odors; and scarring in the region of the posterior fourchette. Scars of former injuries are especially important, since they indicate that the sexual abuse might be a chronic further danger to that chil . cf roblem, heightening the possibility of In addition, note the child's Tanner Stage of genital and breast development, the condition *of anal tone y&;h;rcondition of the hymen, its shape, and its precise horizontal i . Both male and female children may the rectal and perianal areas, also. njuries would include lesions, P resent scarring or injuries in furrowing, creases, discoloration, and poor anal tone. A magnifying colposco e is useful here, also. Any relaxation of the sphincter or excess d!i `latation of the anus - signs often difficult to diagnose -- may also indicate sexual abuse, especially in conjunction with other signs or with the particular history you've taken. The child may cooperate in such a personal1 examination, or may object and not remain stil . T sensitive physical Under no circum- stances should the child be restrained or in any way coerced into continuing with the examination. If you cannot proceed together, then sto P and note for the record what has happened, writing down the chi d's objections uerbatim, if possible. Be as thorough as you can, but -- again - as a health professional and not as a judge and jury. For example if you identify certain bruised tissues, describe what and where those injuries are. Don't speculate that the bruising was "caused by the father" or was a "result of sexual abuse." determined by others later. How the bruising occurred will be An "instant" camera such as a Polaroid Land Camera loaded with color film and used with flash, may also be helpful during the physical examination. Although an many courts seem to favor pictures fr kind of camera can be used, om an "instant" camera rather than the more common slides or prints. An "instant" camera can provide an immediate and permanent (generally tamper-proof) record of bruised and reddened tissues long after they've returned to their normal color. Be aware, however, that a child may become uneasy and even excitable at the presence of a camera, particularly if he or she has 11 been photogra hed b an abuser during sexually explicit or humiliat- ing behavior. xl r so, o der children become embarrassed and will object to having pictures taken of their enital and rectal areas. In these cases, make a record of the chil `s response and put the camera 8 away. Laboratory tests can be ke elements in the chain of evidence of child sexual abuse. You nee the results to make a proper diagnosis i and plan of care; the state needs the results to determine the best way to protect the child, treat the family, and take action against the abuser. Your local police or pmsecutois office can provide you with guidelines for the correct handling and labeling of test specimens and results. A final word of caution: Before ordering any test, consider the physical and emotional condition of the child. If a test will cause further trauma for the child, it would be best to pos one or even cancel it, noting very clearly m the record your reasons or doing so. 4F The following tests are most often used in cases involving child sexual abuse: * If fewer than 72 hours have elapsed since the abuse took place, test for the presence of sperm, acid phosphatase, and blood group antigens. The presence of sperm or seminal fluid is a key piece of evidence in court. Isolate any hairs that ma be present, especially foreign pubic hairs. Take samples of the chil `s saEiua and hair, as i controls. * For female adolescent victims, many experts also recommend a urine pregnancy test, to be repeated at an appropriate interval. * It is advisable to request the following tests, also, to determine the presence of any sexually transmitted diseases: A McCoy cell culture of the rectum and the penile urethra (for males), the vaginal vestibule (for pre ubertal females), or the cervix (for post-menarcheal females) sho d be ordered to detect the UP presence of chlamydia. Currently available non- culture tests for chlamydia are not satisfactory for use in cases of suspected abuse. Cultures for Neisseria gonorrhoeae on a selective medium should be obtained from the throat, urethra, rectum, and vagina and/or cervix, if appropriate. The presence of gonorrhea1 vulvovaginitis in a prepubertal child or a positive gonorrhea culture from the rectum or throat of a child of any age is strong evidence of sexual abuse. But keep in mind that other microorganisms are often mis-identified as N. gonorrhoeae; therefore, a definitive identification should be made in a laboratory using sensitive and specific biochemical identification tests. 12 * If AIDS and s hilis should be requested to Yg are prevalent in your area, then tests etect the presence of these diseases as well: The serologic test for sy hilis (a V.D.R.L. or R.P.R.) should be performed at the time of & e initial examination; if appropriate, this test should be repeated 6 to 12 weeks later. Schedule blood tests for the presence of AIDS (HIV) antibodies, Y with a repeatedly reactive enzyme immunoassay (EIA), !ollowe by a Western blot or a similar, more specific assay. The test should be done immediately, if chronic abuse is indicated, or from 6 to 12 weeks after an acute assault. (NOTE: In acute cases, if testing for AIDS antibodies is done before 6 weeks have passed, the probability of a false negative is very high; but if it% done after 12 weeks have passed, the probability of a false negative or positive is as low as 1 percent.) F'inally, use a rape kit if you can determine that there was penetration or ejaculation by the abuser, that the sexual abuse occurred within the past 72 hours, or that the child has not yet bathed. A rape kit enables the average health professional to treat a victim of sexual abuse, yet collect evidence for possible criminal investigation and prosecution. Commercial rape kits are available from supply houses serving law enforcement crime labs; they cost about $lO-$15 each and are used only once. The data gathered during the assessment process - that is, during the history-taking (the interview) and the physical examination - form the basis for subsequent decisions affecting the child victim, the child's family, and the person or persons responsible for the abuse. In the interests of both health and justice, the data must be complete, accurate, and objective. Section V. Civil and Criminal Proceedings The Constitution and the laws of the United States rovide e+g protection for every person's life, liberty, and well- L ing. protection extends to children, who can't protect themselves from sexual abuse and other dangers. This protection may include civil ~~tec%$zerd custody proceedings, as well as criminal prosecution of rofessionali, Medical evidence, gathered lmtially by health B can be crucial to both the civil and criminal eterminations. If, in the course of its investigation, the child protective services agency suspects that a parent has been sexually abusing a child, the 13 ency may petition the juvenile or family court for permission to ?ic t e certain actions to protect that child. The court may give the a ency permission to take those actions, including the removal of the a `Id from the family, if necessary. The court may then ap oint .a R guardian ad Zitem, an attorney who would represent the c ild,: court; the parents would then be represented by their own different attorney. The petition may ask that the abusin parent leave the home and that another member of that househol f be responsible for the child's welfare. Or it may ask the court to remove the child from the home and seek placement in protective custody with relatives or in a foster care settin . % However, removing children from their own home is a big step. T e courts hesitate to approve such a step unless there is a pre R onderance of evidence that the child was indeed sexually abused at ome and is likely to be abused there again Part of that evidence, of course, would be the assessment of the health professional who saw the child. Very often the real or ima enough to brin about the `ned charge of sexual abuse of a child is % x `ssolution of a troubled marria . In such cases, a secon civil (divorce) court may be involved. If tr at occurs, one parent ma child and the imitation or T petition the `uvenile/family court for custody of the d enial of visitation rights for the other arent. The civil courts may then have two petitions to consider: one Lo m the child protective services agency and one from the parent. Generally, that;`s what occurs on the civil side. On the criminal side however, the police may become convinced that a child has indeed been sexually abused by, say, one parent. They would then take their information to the district attorney, citing all the evidence, including your assessment of the child's physical and mental health. If the evidence is persuasive, the district attorney would then file criminal charges against the alleged abuser. In communities that emplo cons UK a multidisciplinary approach, the public prosecutor may t with several professionals representing different agencies and disciplines (including health) who then arrive at a joint decision on the best way to proceed with the case. At that point the child may be involved in three different cases: a criminal case against the abusive parent, a civil action by child protective services to shield the child from further harm, and a second civil action, a divorce case,. in which one parent requests custody of the child and denial of vlwtation rights for the other. Meanwhile, as the responsible health professional who filed the initial report and examined the child, you may be involved in one, two, or all three proceedings. Your willingness to appear is as important to the health and welfare of the child as your initial 14 history and physical exam are. But the chances are also good that no such request will be made about the case or cases. and that you will hear nothing at all personal Safeguards for investigations and for or a fin BP rivacy virtually seal off all information until a trial is held ruling of the court is made public. However, the safest attitude is to be prepared to testify in any case and to cooperate fully with counsel. The system seeks to be fair to all, yet render protection and `u&ice to children. It is, therefore, a complicated system. For h ealth professionals, generally unfamiliar with the world of civil and criminal law, it may be bewildering and even intimidatin . fl Neverthe- less, in each instance the victimized children, caught in t e vortex of these actions, require the best possible service from all professionals, whether in law enforcement, the courts, social services, or health care. Helping you provide that care, immediately when needed, is the purpose of this Letter. Appendix Initial support for the development of this publication was provided to the Office of the Surgeon General, USPHS, by the Office for Victims of Crime of the Department of Justice, as part of their joint Law/Health Initiative. The following persons contributed to this publication as members of the Surgeon General's Planning Committee: Richard L. Ca e, Detective Lieutenant, Montgomery County Police, Bockvil6, Maryland Robert E. Cramer, Jr., District Attorney, Huntsville, Alabama David E. Crossman, Judge, Hamilton County Juvenile Court, Cincinnati, Ohio Dorothy V. Harris, ACSW, Past President, National Association of Social Workers, Silver Spring, Maryland Leah HarriGon, BN, MSN, CPNP, Assistant Director of Child Protective Services Program, Montefiore Medical Center, Bronx, New York 16 Richard Erugman, MD, Director, C. He 7 Eempe National Child Abuse and Neglect Center, Denver, olorado Jean E. Matusinka, Superior Court Judge (Criminal Division), Los Angeles, California Clare Marie ,I+dgers, Bl'$ MSN, CPNP, Past Secretary, National e;$a&ii of Pe&atnc Nurses and Practitioners, Annapohs, Robert W. ten Bensel, MD, MPH, Professor of Public Health and Pediatrics, University of Minnesota School of Public Health, Minneapolis, Minnesota Joyce N. Thomas RN, MPH, President, Center for Child Protection and Family Support, Washington, D.C. The Planning Committee was a8si8ted by the following people in the federal government: Jane N. Burnley, PhD, Director, Office for Victims of Crime, U.S. Department of Justice, Washington, D.C. Theodore 0. Cron Special Assistant to the Assistant Secretary for Health and the Surgeon General, Washington, D.C. Juanita C. Evans, Division of Maternal and Child Health, USPHS, Bockville, Maryland Helen Howe&n, former Director, National Center for Child Abuse and Neglect, Washington, D.C. William Modzeleski, Director, National Victims Initiative, Office for Victims of Crime, USDJ, Washington, D.C. Betty J. Stewart, ACSW, Actin Associate Commissioner of the Children's Bureau, OHD s% HHS, Washington, D.C. The following publication8 are brief and helpful: Berkowitz, C.D. Sexual Abuse of Children and Adolescents.`Aduans in Pediutrks. 34:275312. 1987. 16 Child Abuse!NeglectlSexual Abuse, a Gujde for Prevention, De~chp$ec~t,ment, and Fo!low-up m BHCD+ Prqgrams Pi&burg h Produced Jomtl `Graduate School o P by the Umverslty of Public Health and the Division of Maternal and Child Health (HRS+IUSPHS)~of the g.E y;ep6&rnent of Health and Human Services. Washmgton, . . . Elvik, S.L., Berkowitz, C.D., and Greenberg, C.S. "Child Sexual Abuse: the Bole of the NP." Nurse Practitioner. 11:1:15 ff. Johnson, C.F. The Sexually Abused Child: A Pediatrician's Approach to the Interview. Children's Hosp. Press. Columbus, 0. 1986. Jones, D.P.H. and McQuiston, M. Interviewing the Sexually Abused Child. Kern e National Center for the Prevention and Treatment o P Child Abuse and Neglect. Denver, CO. 1985. Krugman, RD. "Becognition of Sexual Abuse in Children." Pediatrics in Review. 8:2530. 1986. Sgroi, Suzanne M., Handbook of Clinical Intervention in Child Sexual Abuse. Lexington Books, Lexington, Ma88. 1982. Smith, Sandra Butler. "Children and the Courts." California Pediatrician. 2:2:19-21. 1986. ten Ben&, Robert W. Integrated Glossary of Normal Child Sexuality and Child Sexual Abuse Terms for Juvenile Justice Professionals. National College of Juvenile and Family Law. Reno, Nevada. 1987.