What is the appropriate medical response and use of a Sexual Assault Response Team (SART) kit in pediatric cases of sexual assault?

Appropriate Medical Response and Use of SART Kit in Pediatric Sexual Assault Cases

The appropriate medical response to pediatric sexual assault requires immediate forensic examination using a Sexual Assault Response Team (SART) kit within 72 hours of the assault for optimal evidence collection, followed by comprehensive medical care including STI prophylaxis and psychological support. 1

Initial Medical Response

Timing of Examination

• Acute cases (within 72 hours of assault): Immediate forensic examination is critical as DNA evidence can be collected for at least 72 hours after assault 1
• Between 4-7 days: Contact local authorities to determine if evidence collection is still useful 1
• After 1 week: Examination and treatment should proceed without forensic collection 1

Personnel Requirements

• Examination should be performed by specially trained professionals:
  • Physician who specializes in child abuse OR
  • Nurse with sexual assault care training 1
  • These specialists ensure proper documentation and maintain chain of evidence

Components of SART Kit Examination

Medical History and Documentation

• Document detailed history without value judgments or interpretations
• Use direct quotes from the child when possible 2
• Avoid terminology like "hymen not intact" 1
• Document all findings meticulously as records may be subpoenaed 1

Physical Examination

• Complete head-to-toe examination with detailed genital examination 3
• Video colposcopy is recommended to:
  • Document genital trauma including microtrauma
  • Allow adolescents to view their own examination (which many find beneficial) 1
• Important: Most victims will have unremarkable anogenital examinations, especially when examined non-acutely 4
  • Only 2.2% of sexually abused girls examined non-acutely have diagnostic physical findings
  • 21.4% of those examined acutely show injuries 4

Evidence Collection

• Clothing should be stored in paper (not plastic) bags 1
• Collect forensic evidence from all potential sites:
  • Body swabs
  • Clothing
  • Other relevant objects 5

STI Testing and Prophylaxis

Recommended screening sites:

Test	Throat	Vagina	Cervix/Urethra	Anorectal	Blood
Gonorrhea culture	Yes	No	Yes	Yes	NA
Chlamydia culture	No	No	Yes	Yes	NA
NAAT for chlamydia, gonorrhea	No	Yes	Yes	No	NA
Trichomoniasis, bacterial vaginosis, candidiasis	No	Yes	No	No	NA
HIV, hepatitis B, syphilis	No	No	No	No	Yes

• Provide STI prophylaxis per CDC guidelines 1, 2
• Consider HIV post-exposure prophylaxis within 72 hours if indicated 2
• Offer hepatitis B vaccination if not previously vaccinated 2

Pregnancy Prevention (for females)

• Emergency contraception should be offered if within 120 hours of assault 1
• Document pregnancy status at time of evaluation 1

Special Considerations for Different Age Groups

Prepubertal Children

• May require different timing and type of examinations compared to adolescents 6
• Partial tears of hymen, abrasions, and contusions may heal completely, emphasizing importance of urgent evaluations 6

Adolescents

• May have concerns about confidentiality and stigma
• Should be interviewed without parents present 1
• May benefit from watching their own examination via video colposcopy 1

Male Victims

• Require special attention to psychological concerns about masculinity and sexual orientation 2
• Need appropriate STI testing at penetration sites, particularly anal 2

Mandatory Reporting and Safety

• All states have mandatory reporting laws for suspected child abuse 2
• Report to child protective services and/or law enforcement immediately 2
• Assess immediate safety concerns related to perpetrators 2
• Ensure child's safety before discharge 2

Follow-up Care

Medical Follow-up

• Schedule follow-up within 1 week to assess injury healing 2, 7
• Plan repeat STI testing at 2 weeks, 6 weeks, 3 months, and 6 months 2

Psychological Support

• Assess for suicidal/homicidal ideation or self-harm behaviors 1, 2
• Arrange trauma-focused cognitive behavioral therapy 2
• Provide contact information for sexual assault support services 2
• Monitor for PTSD, depression, and anxiety 2

Common Pitfalls to Avoid

1. Inadequate examination: Every child with suspected sexual abuse requires a complete medical evaluation, not just a cursory examination 3

2. Misinterpreting normal findings: Most victims will have normal or non-specific physical examinations 4

3. Poor documentation: Avoid value judgments and interpretations; use precise terminology 1

4. Neglecting psychological needs: Mental health assessment is critical as sexual assault is associated with increased risk of depression, suicidal ideation, and self-harm behaviors 1

5. Failing to ensure follow-up: Close medical follow-up is essential to mitigate adverse consequences and decrease long-term comorbidities 7