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Medical Evaluation for Child Sexual Abuse: What the PNP Needs to Know

      Abstract

      Sexual abuse is a problem of epidemic proportions. Pediatric nurse practitioners (PNPs) will most likely encounter sexually abused children in their practice, both those who have been previously diagnosed and others who are undiagnosed and require identification by the PNP. This continuing education article will discuss the medical evaluation of children with concerns of suspected sexual abuse. Acute and non-acute sexual abuse/assault examinations will be discussed. Physical findings and sexually transmitted infections concerning for sexual abuse/assault will also be discussed.

      Key Words

      Objectives

      Based on the content of the article, you will be able to:
      • 1.
        Identify prepubertal female genital anatomy.
      • 2.
        Describe why a normal ano-genital examination does not negate the possibility of sexual abuse.
      • 3.
        State when to report a concern of suspected sexual abuse to child protective services.
      • 4.
        Identify abnormal ano-genital examination findings.
      • 5.
        Recognize sexually transmitted infections that are of concern for sexual abuse and warrant reporting to child protective services.
      • 6.
        Describe three essential components of the medical evaluation for child sexual abuse.
      Sexual abuse is a problem of epidemic proportions. According to the

      U.S. Department of Health & Human Services. (2010). Child maltreatment 2008. Retrieved from http://www.childwelfare.gov/cam/prevalance

      ), more than 70,000 children were victims of sexual abuse in 2008. Twenty-five percent of girls and 16% of boys in the United States experience sexual abuse before the age of 18 years (
      • Matkins P.P.
      • Jordan K.S.
      Pediatric sexual abuse: Emergency department evaluation and management.
      ). Studies have suggested that approximately 1% of children experience some form of sexual abuse every year (
      • Kellogg N.
      The evaluation of sexual abuse in children.
      ). Sexual abuse perpetrators are most often someone the child knows, trusts, and even loves. Compared with women, men are much more frequently identified as sexual abuse perpetrators; however, women also sexually abuse children. Adolescents are perpetrators in at least 20% of sexual abuse cases (
      • Kellogg N.
      The evaluation of sexual abuse in children.
      ).
      It is vital for PNPs to recognize physical findings of sexual abuse, abnormal sexual behaviors, victim disclosures of sexual abuse, and infections that raise concern for sexual abuse.
      Pediatric nurse practitioners (PNPs) will most likely encounter sexually abused children in their practice, both those who have been previously diagnosed and others who are undiagnosed and require identification by the PNP. A competent medical evaluation for child sexual abuse requires a specific skill set and knowledge. Knowledge of normal ano-genital anatomy is a fundamental essential (see Figure 1). It is vital for PNPs to recognize physical findings of sexual abuse, abnormal sexual behaviors, victim disclosures of sexual abuse, and infections that raise concern for sexual abuse. The medical evaluation for child sexual abuse includes obtaining the history of abuse from the child and/or non-offending parent/guardian; identifying and documenting injury or infection; treating medical conditions arising from the abuse; providing reassurance to the child and parent; assessing the child’s emotional and physical well-being and making appropriate referrals; reporting concerns of sexual abuse to Child Protective Services (CPS); and documenting findings accurately and thoroughly (
      • Adams J.A.
      • Kaplan R.A.
      • Starling S.P.
      • Mehta N.H.
      • Finkel M.A.
      • Botash A.S.
      • Shapiro R.A.
      • et al.
      Guidelines for medical care of children who may have been sexually abused.
      ). The PNP completing a medical evaluation for suspected sexual abuse may be required to testify in court regarding statements made by the child, physical examination findings, and related documentation.
      Figure thumbnail gr1
      Figure 1Normal ano-genital anatomy. This figure is available in color online at www.jpedhc.org.
      Children and adolescents with a concern of suspected sexual abuse may present to their PNP in a variety of ways. They may have made a verbal disclosure to a caregiver or had a caregiver witness an incident of sexual abuse. The caregiver may have suspicions of sexual abuse based on behaviors exhibited by the child or other factors. The child may present with an ano-genital physical finding or a sexually transmitted infection (STI) that raises concerns about sexual abuse, or the child may disclose sexual activity at the time of the health care visit.
      The PNP must consider the possibility of sexual abuse when a child or adolescent presents with a behavioral or psychiatric disorder (
      • Putman F.W.
      Ten-year research update review: Child sexual abuse.
      ). A child presenting with depression, suicidal ideation, substance abuse, post-traumatic stress disorder, or attention deficit hyperactivity disorder should be asked a few sexual abuse screening questions to explore the possibility of sexual abuse. Children, especially young children, presenting with age-inappropriate knowledge of sex should be assessed for possible sexual abuse or exposure to sexually explicit behaviors (
      • Hornor G.
      Sexual behavior in children: Normal or not?.
      ). All well-child visits should include a few developmentally appropriate screening questions for sexual abuse because spontaneous disclosure of sexual abuse may not be offered (
      • Hornor G.
      A normal ano-genital exam: Sexual abuse or not?.
      ). Parents and children should be separated for questioning if possible. Box 1 provides appropriate screening questions. Children often are reluctant to disclose sexual abuse for a variety of reasons including fear, guilt, embarrassment, threats, family loyalty, and concern regarding consequences of disclosure. Many children never disclose their sexual abuse or disclose weeks, months, or even years after the latest incident.
      Sexual abuse screening questions

        Parent/caregiver

      • 1.
        Do you have any concerns of sexual abuse?
      • 2.
        Were you or your partner a victim of child sexual abuse?
      • 3.
        Is there a history of sexual abuse in your family or your partner’s family?
      • 4.
        Is your child ever in contact with anyone who has been accused of sexually abusing a child or adolescent?

        Child

      • 1.
        Have the child identify his or her body parts.
      • 2.
        Have the child identify his or her private parts (i.e., vagina/penis, anus, breasts).
      • 3.
        Using the child’s words for his or her private parts, ask if anyone has ever touched, tickled, hurt, or put anything in their private parts.

        Adolescent

      • 1.
        Introduce the subject of sex. Clarify the adolescent’s meaning of the word.
      • 2.
        Ask the adolescent if he or she has ever had sex when he or she wanted to.
      • 3.
        If the answer is yes, ask the age of the person the adolescent had sex with.
      • 4.
        Ask the adolescent if anyone ever made him or her have sex or touched him or her in a sexual way when he or she did not want them to.

      Acute Sexual Abuse/Assault

      Appropriate triage of a child or adolescent presenting with a concern of sexual abuse or assault is essential. Crucial information to gather prior to beginning a sexual abuse physical examination includes what happened to the child’s body (i.e., what body part of the perpetrator touched where on the child, such as the perpetrator’s penis in child’s vagina), when the sexual abuse last happened, who perpetrated the sexual abuse, and any past or current physical concerns (e.g., genital/anal bleeding, discharge, or pain) (
      • Giardino A.P.
      • Finkel M.A.
      Evaluating child sexual abuse.
      ). The timing of the latest incident of sexual abuse is important in determining the need for the collection of trace forensic evidence and prophylaxis for STIs and/or pregnancy. The American Academy of Pediatrics recommends that when the alleged sexual abuse has occurred within 72 hours or there is an acute ano-genital injury, the physical examination should be conducted immediately (
      • Adams J.A.
      • Kaplan R.A.
      • Starling S.P.
      • Mehta N.H.
      • Finkel M.A.
      • Botash A.S.
      • Shapiro R.A.
      • et al.
      Guidelines for medical care of children who may have been sexually abused.
      ). Adolescents experiencing acute sexual abuse/assault may require prophylaxis for pregnancy and/or STIs. Typically, prepubertal children are not given prophylaxis for gonorrhea or chlamydia because of the low incidence of these STIs in sexually abused children (
      • Adams J.A.
      Guidelines for medical care of children evaluated for suspected sexual abuse: An update for 2008.
      ). Human immunodeficiency virus prophylaxis may be warranted for both children and adolescents experiencing acute sexual abuse/assault, especially coupled with ano-genital injury and perpetrator risk factors. In acute situations, the collection of trace forensic evidence to be analyzed for the perpetrator’s semen, saliva, or blood may be warranted. Collection of forensic evidence from the victim includes body swabs, hair samples, and blood samples, as well as clothing and linens. Forensic evidence should be collected by a medical provider with training and expertise and therefore may necessitate the transfer of the patient to a more appropriate provider, such as an emergency department or child advocacy center.

      Non-Acute Sexual Abuse/Assault

      Children presenting with a non-acute concern of sexual abuse require a thorough medical evaluation consisting of a physical examination, medical history including a minimal facts history of the sexual abuse concern, and a familial psychosocial history. PNPs must be aware of local resources available for sexual abuse evaluations. Communities may possess multidisciplinary teams with expertise in assessing children with sexual abuse concerns such as those found at a child advocacy center or a children’s hospital; children presenting with a non-acute concern of sexual abuse may be best served by referral. However, may communities do not possess such services; therefore, a basic understanding of the medical evaluation for child sexual abuse is crucial for every PNP.

      Medical History

      The diagnosis of sexual abuse is typically made based on the history of abuse given by the child, because less than 5% of children who are sexually abused will have a physical finding upon examination (
      • Sapp M.V.
      • Vandeven A.M.
      Update on childhood sexual abuse.
      ). This lack of ano-genital physical findings can be explained by several factors: a history of sexual abuse involving noninvasive forms of abuse; elasticity of the hymen and other ano-genital structures; and healing of ano-genital injuries without residual injury (
      • Hornor G.
      A normal ano-genital exam: Sexual abuse or not?.
      ). Therefore when a child presents with a concern of sexual abuse, obtaining a comprehensive medical history from the patient and family is crucial. As with providing any clinical care, the medical history will serve to guide the physical examination. The PNP is not conducting a comprehensive forensic interview but rather obtaining a medical history for purposes of medical treatment and diagnosis and to ensure the safety of the child.
      Obtaining a medical history in cases of suspected sexual abuse is a multi-step process consisting of the parental/caregiver concern of sexual abuse; a familial psychosocial history; a detailed medical history of the child with a review of systems focusing on any ano-genital complaints such as bleeding, discharge, pain, or past genital injury; the child’s history of sexual abuse, ideally obtained without the parent/caregiver present; and preparation of the child for the physical examination (
      • Giardino A.P.
      • Finkel M.A.
      Evaluating child sexual abuse.
      ). An adolescent medical history should include age of menarche and date of last menstrual period. Box 2 indicates pertinent psychosocial information to obtain from the parent or caregiver. Additional information to obtain includes any witnesses to the alleged sexual abuse, changes in the child’s behavior, specifically sexualized behaviors, and—especially in young children—the names the child uses for body parts (e.g., breasts, vagina, penis, and anus). The parent/caretaker interview should take place without the child present whenever possible. Once this information has been obtained the PNP is better prepared to talk with the child about the sexual abuse concern.
      Psychosocial information
      • 1.
        Draw a family tree; include the names and ages of mother/father/siblings.
      • 2.
        Indicate who lives in the home with the child.
      • 3.
        If the child visits another parent, who lives in that home?
      • 4.
        Have there been previous concerns of sexual abuse for this child or other children in the family?
      • 5.
        Has there been previous involvement with Child Protective Services? If yes, why?
      • 6.
        Has there been parental involvement with law enforcement? If yes, why?
      • 7.
        Has there been a parental history of child sexual abuse, physical abuse, neglect, or involvement with Child Protective Services?
      • 8.
        Has there been parental alcohol or drug use?
      • 9.
        Has there been parental mental health/mental retardation issues?
      • 10.
        Has there been a familial history of domestic violence?
      • 11.
        Is the child exposed to anyone with a history of sexually abusing children?

      Obtaining a History From the Child

      The most crucial step when talking to a child about alleged sexual abuse is to create an environment that is safe, private, free of distractions, and child-friendly. Whenever possible, children 3 years or older should be interviewed without a parent present (
      • Giardino A.P.
      • Finkel M.A.
      Evaluating child sexual abuse.
      ). One can begin the conversation by talking about less threatening subjects, such as colors, school, or likes and dislikes. When talking with the child the PNP should utilize open-ended, non-leading questions asked in a developmentally and culturally appropriate manner. Younger children should be asked to identify body parts, including private parts, using the words that the child uses to identify private parts. The child should be asked if anyone touched, tickled, hurt, or put anything inside each private part. Interviewing tools such as anatomic drawings with private parts the child or adolescent can point to and name may assist in obtaining a medical history.
      With older children and adolescents, the PNP can focus the discussion by talking about private parts, have the child identify private parts, and then ask about touching. Adolescents need to be asked about prior consensual sexual activity using terms the adolescent understands, and the adolescent’s definition of sex, the age of the partner(s), and the timing of the sexual activity should be clarified. Past consensual sexual intercourse (vaginal or anal) may affect the interpretation of a physical finding on ano-genital examination, making it impossible to state that the finding is the result of sexual abuse versus consensual sexual activity. Also, the age of the adolescent’s sexual partner(s) may necessitate a referral to CPS (i.e., a 14-year-old having vaginal intercourse with a 25-year-old); the PNP must be aware of state laws defining the age of sexual consent. When interviewing a child or adolescent regarding their sexual abuse, the PNP needs to gather enough information to ensure the child’s safety by reporting to CPS and to guide the physical examination regarding the need for STI and pregnancy testing. However, the PNP also should keep in mind that the child most likely will be required to undergo a forensic interview at a child advocacy center or by CPS/law enforcement, and it is not in the best interest of the child for the PNP to attempt a detailed forensic interview. Thorough and accurate documentation of the entire medical evaluation is crucial, particularly the statements made by the child describing his or her sexual abuse.

      Physical Examination

      Children and adolescents should have the choice to have a parent/caretaker in the room with them for the physical examination to provide support. The physical examination, including the ano-genital examination, should be explained to the child/adolescent and parent in detail. The history of sexual abuse given by the child typically dictates the type of STI testing necessary. For instance, if a child gives a history of a penis penetrating his or her mouth, a throat culture for GC should be obtained. Box 3 provides STI testing indications according to the history given by the child. Every child should have a complete head-to-toe physical examination, with a special inspection for any additional signs of trauma such as bruising, abrasions, or lacerations to the body beyond the ano-genital region. Careful written and photographic (if possible) documentation should be noted.
      Sexually transmitted infection testing per child history
      Tabled 1
      Genital–genital contactUrine DNA amplification for chlamydia/GC (positive urine should be confirmed by genital culture or DNA swab prior to treatment in prepubescent children)
      Or
      Genital culture for chlamydia/GC
      Or
      Genital swab for DNA amplification for chlamydia/GC
      And
      HIV/RPR/hepatitis A antibody/hepatitis B surface antigen
      And
      Trichomonas culture (if symptomatic or if perpetrator is known to be positive)
      And
      Urine pregnancy (adolescent female)
      Anal-genital contactAnal culture chlamydia/GC
      And
      HIV/RPR/hepatitis A antibody/hepatitis B surface antigen
      Oral-genital/anal contact
       Child to perpetratorOral culture Chlamydia/GC
       Perpetrator to child
      Child's genitalsUrine DNA amplification for chlamydia/GC
      Or
      Genital culture for chlamydia/GC
      Or
      Genital swab for DNA amplification for chlamydia/GC
      Child's anusAnal culture for chlamydia/GC
      All adolescent femalesComplete urine HCG
      All adolescent females or malesUrine DNA amplification for chlamydia/GC
      DNA, Deoxyribonucleic acid; GC, gonorrhea, HCG, human chorionic gonadotropin; RPR, rapid plasmin reagin.
      The ano-genital examination for both prepubertal and pubertal boys involves a thorough visualization and inspection of the anus and genitalia utilizing an adequate light source. Sexual maturity should be noted. Testes should be palpated to ensure descension and lack of masses or tenderness. Any trauma, lesions, or rashes should be noted. Traumatic findings that raise a concern for sexual abuse in the absence of a plausible history of accidental trauma include lacerations, abrasions, bruises, and perianal scarring (
      • Adams J.A.
      • Kaplan R.A.
      • Starling S.P.
      • Mehta N.H.
      • Finkel M.A.
      • Botash A.S.
      • Shapiro R.A.
      • et al.
      Guidelines for medical care of children who may have been sexually abused.
      ). Ano-genital lesions that are of concern but not diagnostic for sexual abuse include warts (human papilloma virus [HSV]) and herpes (herpes simplex virus) (
      • Kellogg N.
      The evaluation of sexual abuse in children.
      ). Ano-genital warts are diagnosed clinically. Ano-genital lesions of concern for HSV should be confirmed by viral culture with typing or rapid polymerase chain reaction (
      • Adams J.A.
      • Kaplan R.A.
      • Starling S.P.
      • Mehta N.H.
      • Finkel M.A.
      • Botash A.S.
      • Shapiro R.A.
      • et al.
      Guidelines for medical care of children who may have been sexually abused.
      ). Anal dilatation should be noted. Marked anal dilatation greater than 2 cm without the presence of stool in the vault may support a child’s history of anal penetration; if noted on examination, the child should be referred to a sexual abuse examination expert for confirmation and interpretation of the finding (
      • Adams J.A.
      • Kaplan R.A.
      • Starling S.P.
      • Mehta N.H.
      • Finkel M.A.
      • Botash A.S.
      • Shapiro R.A.
      • et al.
      Guidelines for medical care of children who may have been sexually abused.
      ). If acute traumatic findings such as bruising, swelling, abrasions, or lacerations are noted on ano-genital examination, consideration should be given to referring the child to an emergency department or child advocacy center for an immediate examination and collection of trace forensic evidence.
      The ano-genital examination for girls also requires an adequate light source. The patient should be placed in a supine frog-leg position, or stirrups can be used. Labial traction should be gently applied, pulling toward the examiner to visualize the genital structures and the hymenal opening. If a hymenal opening cannot be visualized, one can attempt to readjust labial traction or float the hymen with a small amount of water or saline solution with use of a syringe or saline bullet (
      • Hornor G.
      A normal ano-genital exam: Sexual abuse or not?.
      ). An inspection should be conducted for any acute injuries such as bruising, edema, bleeding, or lacerations of the hymen, posterior fourchette, other genial structures, or anus (Figure 2). An acute ano-genital injury coupled with a history of sexual abuse given by the child or the lack of a history of an accidental injury requires referral for trace forensic evidence collection. Sexual maturity should be noted, along with any lesions, especially warts or herpetic lesions. Findings that raise concern for non-acute sexual abuse are areas of missing hymenal tissue or healed hymenal transections extending entirely or nearly entirely through the hymen (
      • Adams J.A.
      • Kaplan R.A.
      • Starling S.P.
      • Mehta N.H.
      • Finkel M.A.
      • Botash A.S.
      • Shapiro R.A.
      • et al.
      Guidelines for medical care of children who may have been sexually abused.
      ). These findings should be confirmed by also examining the patient in the knee-chest position to allow gravity to allow hymenal tissue to fall into the visual field, thereby negating the previous finding. Other non-acute findings that raise concern for sexual abuse include perianal scarring or scarring of the posterior fourchette (
      • Adams J.A.
      • Kaplan R.A.
      • Starling S.P.
      • Mehta N.H.
      • Finkel M.A.
      • Botash A.S.
      • Shapiro R.A.
      • et al.
      Guidelines for medical care of children who may have been sexually abused.
      ). Any non-acute finding necessitates a referral to a sexual abuse examination specialist for confirmation of the finding, especially in the absence of a history of sexual abuse given by the child.
      Figure thumbnail gr2
      Figure 2Acute ano-genital injury. This figure is available in color online at www.jpedhc.org.
      The prepubertal hymen is very sensitive to touch, and contact during examination should be avoided if possible (Figure 3). Because of the release of estrogen the pubertal hymen is not sensitive to touch, is much more elastic, and can easily be palpated with a cotton tip applicator to inspect the integrity of the hymen (Figure 4). STIs can raise a strong concern for sexual abuse. Box 4 provides the interpretation of a positive STI finding, diagnostic testing, and treatment.
      Figure thumbnail gr3
      Figure 3Normal prepubertal hymen. This figure is available in color online at www.jpedhc.org.
      Figure thumbnail gr4
      Figure 4Normal pubertal hymen. This figure is available in color online at www.jpedhc.org.
      Interpretation of sexually transmitted infection results
      • Adolescents with positive sexually transmitted infection or pregnancy testing must rule out consensual sexual activity as the source of the infection/pregnancy.
      • Prepubertal child with a positive urine DNA amplification should have a complete vaginal/urethral culture or other DNA amplification test prior to treatment.
      Chlamydia: Positive genital/anal culture; positive urine DNA amplification; positive genital swab DNA amplification—Of concern for sexual abuse; report to CPS
      Gonorrhea: Positive oral/genital/anal culture; positive urine DNA amplification—Of concern for sexual abuse; report to CPS
      Trichomonas: Positive genital culture; positive wet mount—Of concern for sexual abuse; report to CPS
      Syphilis: Positive serology; negative perinatal transmission—Of concern for sexual abuse; report to CPS
      HIV: Positive serology; negative risk factors—Of concern for sexual abuse; report to CPS
      Ano-genital herpes: Positive HSV culture or PCR; no history given of sexual abuse and otherwise normal ano-genital examination; explore auto-inoculation—Can be sexually transmitted; report to CPS with caveat that it is not diagnostic of sexual abuse and can be non-sexually transmitted
      Ano-genital warts: Diagnosed clinically; explore perinatal or autoinoculation—Can be sexually transmitted; report to CPS with caveat that it is not diagnostic of sexual abuse and can be non-sexually transmitted
      CPS, Child Protective Services; DNA, deoxyribonucleic acid; HSV, herpes simplex virus; PCR, polymerase chain reaction.
      Fewer than 5% of children who give a history of sexual abuse will have a physical finding of concern for sexual abuse upon an ano-genital examination (
      • Heger A.
      • Ticson L.
      • Velasquez O.
      • Bernier R.
      Children referred for possible sexual abuse: Medical findings in 2384 children.
      ). The ability of the PNP to provide reassurance to the child and family that despite what has happened to them their body is normal, just the same as any other girl/boy, is crucial in helping children and families heal following sexual abuse. For the few patients who do have a finding on physical examination, the PNP can also provide reassurance that this finding will not affect their ability to have sex or babies when they get older and that only a doctor or nurse conducting an examination could tell that something had happened. The patient can be reassured that no one else will ever need to know unless the patients chooses to share it with someone.
      The physical examination may reveal additional medical needs that may necessitate referral for ongoing medical care. Not all children who have been sexually abused need ongoing mental health therapy; however, a referral should be made to a therapist with expertise in working with children with a history of sexual abuse to determine the need for ongoing therapy.

      Ensuring Safety

      Anticipatory guidance and screening for sexual abuse needs to occur at well-child check-ups and when children present with behavioral and/or physical symptoms that raise concerns about sexual abuse.
      The PNP performing a sexual abuse medical evaluation plays a crucial role in ensuring patient safety. CPS must be notified if the PNP has a concern of possible sexual abuse; certainty is not required to report. PNPs should know their state laws defining their responsibility as a mandated reporter. A report should be made to CPS if the child gives the PNP a verbal history of sexual abuse, has an ano-genital finding that raises concern for abuse, or is diagnosed with an STI that raises concern for abuse. Failure to report suspected sexual abuse not only leaves that child at risk for further abuse but also potentially places additional children at risk. PNPs who fail to report a concern of suspected sexual abuse also risk professional liability. PNPs should inform the non-offending parent/caregiver of their concerns of suspected sexual abuse and the need to report to CPS. PNPs should verbally notify CPS of their concerns while the child is still present in the office/clinic, and a safety plan should be verified with CPS before the child is discharged home.
      Sexual abuse is a problem that PNPs are likely to encounter in their practice. Anticipatory guidance and screening for sexual abuse needs to occur at well-child check-ups and when children present with behavioral and/or physical symptoms that raise concerns about sexual abuse. Parents need to be educated about how to best protect their children from sexual abuse. PNPs should be familiar with local services available for the assessment, investigation, and treatment of sexual abuse. PNPs should know and utilize local or state child sexual abuse examination experts for consultation and referral as needed. The disclosure of sexual abuse often places the child and family in a state of crisis. A thorough and competent medical evaluation for child sexual abuse is a vital step in ensuring the safety of the child and helping the child and family to heal.

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        Guidelines for medical care of children who may have been sexually abused.
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      1. U.S. Department of Health & Human Services. (2010). Child maltreatment 2008. Retrieved from http://www.childwelfare.gov/cam/prevalance

      Biography

      Gail Hornor, Pediatric Nurse Practitioner, Nationwide Children’s Hospital, Center for Child and Family Advocacy, Columbus, OH.

      Linked Article

      • Correction
        Journal of Pediatric Health CareVol. 26Issue 2
        • Preview
          In the article, “Medical Evaluation for Child Sexual Abuse: What a PNP Needs to Know” (Journal of Pediatric Health Care, 25[4]:250-256), there is an error in Box 3. For the antibody testing it should read hepatitis C rather than hepatitis A.
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