12/21/01

Q. What resources are available for child sexual assault training?

A. A provider at an I/T/U site asked the above question. I posed it to
members of the MCH listserv and found that there are several resources
available.

'There is training on child physical and sexual abuse through the Making
Medicne project. This project is funded by the Administration for
Children Youth and Families through an interagency agreement with IHS.
University of Oklahoma psychologists, Dr. Barbara Bonner and Dr. Dee
Bigfoot provide the training. The training includes an initial 40 hours
of didactic sessions and seminars as well as clinical consultation
(usually by phone) over a period of six months. There is examiner and
interviewing training, as well as child counseling. 

This training should be available by making arrangements with Dr. Bonner
or Dr. Bigfoot at (405)271-8858.'

"Ms Ramona Williams in Rockville, MD   phone via OPH 301-443-3024 should
be able to answer the questions regarding the IHS Child Abuse Training
Programs.  The AAP and AAFP have programs available as well\... these
are directed toward Physicians / Clinical Providers and information
about them can be obtained via their respective web site."

"The best sexual assault program I am aware of is based in California. 
The contact person is Sally Montoya 310-222-3091.  The midwives at Pine
Ridge have attended their sexual assault training for adults and it was
excellent.  They also have a child sexual assault program." 

"There is a CE course in Anchorage this Jan. The course is sponsored by
Providence Medical Center. They have a sexual assault program."

"I attended a two day conference given by *Contemporary Forums* last May
in Atlanta where one of the topics was sexual abuse.  Other topics were
related to the aftermath of sexual abuse like Post Traumatic Stress
disorder, depression.  Contemporary Forums has a web page just enter the
words \"Contemporary Forums\" in the search engine of your choice." 

"There is a great program in January that is put on by the San Diego
group annually- it is usually the end of Jan. They also do week long
mini internships for providers to train them on how to do forensic
exams. There is also a group in Alabama that does the same- I will try
to find the info for you. There is also an annual conference in Phoenix
on child maltreatment but I think it is in the Fall of each year."

"Outside of IHS one center of excellence is University of California San
Diego that has both formal courses on Child Physical and Sexual Abuse
and specific training in colposcopy. I do not have contact numbers, but
would probably come up on websearch e.g., Center for Child
Maltreatment."

"I want to warn of some people, one in particular, who has set up a
program that is less than ideal, here in S.Dakota.  And he is giving
national workshops.  I had the opportunity to observe him, and actually
ended up testifying for the defense.  But his process is not objective,
nor do they do complete exams.  Maybe he has changed in the last few
years."

"We had 2 sessions at Pediatric Conferences held here in the Phoenix
Area that Dottie Meyer arranged.  Specifically covered was the
differences in the pediatric gynecologic exam vs. the adult gynecologic
exam that we GYNs have all trained with.  However, the session was
oriented for pediatricians, who often are not as comfortable with the
gynecologic exam, especially when it may have forensic purposes.  The
last presenter was a pediatrician who [regularly]{.underline} does these
exams here locally, testifies in court relative to her findings, and is
on staff at Maricopa Medical Center.  The other was a pediatrician who
has done some \"high profile\" exams and testimony.

We are lucky enough to have an arrangement with the university to do
these exams\...it helps in court cases to have the expert testimony and
the child only has one exam\..."

"Some thoughts on the Child Sexual Abuse (CSA) evaluation:

 - Each IHS SU should think carefully as to how they wish to address
this issue with a protocol in place.

 - The CSA examination is a very specialized examination which includes
both an interview and a medical examination.  The goal is to perform a
one time examination, so that the child is not exposed to multiple
examinations and re-victimization. 

 - CSA medical examinations are generally divided into two time frame
categories: less than 72 hours or after 72 hours post incident.  The
majority of  CSA incidents are reported after 72 hours at which
point the the forensic interview becomes the most important aspect of
the CSA examination.  After 72 hours, a colposcopy examination is
essential for proper evaluation.  This requires specialized training and
maintenance of examination skills.  In the PX area, we have selected
performing minimally 12 examinations per year for maintenance of
skills.  We have nothing to support this number, and Sylvia Strickland
and I just pulled it out of the air.  Acute/emergent care evaluation
should be provided by clinicians at every SU.  In the PX area, we have
held a yearly pediatric meeting for the past 14 years where an updating
of both acute skills and discussion of CSA is provided.  (Except last
year, when I couldn\'t get it on the national agenda.)   In cases where
expert testimony is required, this also provides documentation of
ongoing training.

 - If an IHS SU wishes to provide medical evaluations in cases of
allegations after 72 hours, telemedicine is an excellent alternative. 
In the PX area, we have been fortunate to have Jane Powers, FNP, at the
U&O Service Unit who has developed, with the support of her SUD/CD and
the MCH Program, a program with Astrid Hegar (LAC+USC Medical Center)
and Liah Lamb (CARES Unit, St Lukes Regional Medical Center, Boise
Idaho), funded by the OVC.  This program provides, not only exceptional
training for the individual clinician, but also direct access to these
two of the top CSA experts in the US for evaluation of colposcopy
examinations.  Personally, for multiple reasons, I believe that
examinations of children, in the after 72 hour category, belong in
specialized centers where a comprehensive examination can be performed. 
In more isolated geographical areas where these centers are not
accessible and available, I believe Jane\'s Program is a reasonable and
acceptable alternative.  It provides not only an in-depth 4 day didactic
training, but also, accessibility to and ongoing training/skill building
from national experts.  In this past fiscal year, 12 IHS physicians took
part in this training.  Interestingly, one was from the Northern
Cheyenne Clinic in Lame, Deer, Montana, (Melissa Broomhall).  Jane may
be reached at 1-800-635-3324 ext 6839 or by the IHS e-mail.

 - At least in AZ, Nevada, and Utah, the US Attorney\'s Offices have
definite ideas as to how they wish examinations to take place.  All
protocols/plans need to be discussed with these offices for input and
coordination.

 - Finally, Dean Effler developed an education slide program on CSA. 
Each SU in the IHS should have received a copy of this slide series. 
This are a good review of acute physical presentations of CSA.  It would
seem helpful that, after initial training, these could be reviewed at
intervals.  Hopefully, these are still available at each IHS site."