RESULTS. A substantial minority of children reported elevated concern about their lack of exam knowledge, the staff's unfamiliarity, someone inspecting their private parts, and their health. Most adults reported elevated concern about their lack of exam knowledge and their children's health. A substantial minority of adults also reported elevated concern about their children's distress and the exam's potential painfulness. Child's age but not prior exam experience was correlated with some of these concerns.

CONCLUSIONS. Participants approached the exam with specific concerns. These data may inform interventions aimed at minimizing distress and facilitating adjustment.

Search terms: Child sexual abuse, medical fears, nonoffending adult guardians, pediatric anogenital exam, preparatory interventions

Although obtaining an accurate abuse history remains the most important objective when investigating allegations of child sexual abuse, children also may undergo anogenital examination. In fact, the introduction of the colposcope approximately 20 years ago has contributed to an increased emphasis on the medical diagnosis of child sexual abuse.

The colposcope is a light source attached to a pair of binoculars that permits closer inspection of the child's genital and anal areas. A camera attached to this instrument allows the medical examiner to take a photographic record of rashes, scars, bruises, swelling, and other marks that may be consistent with injury or infection.

Although the colposcope never makes contact with the child's body, the examiner typically places his/her hands on the child's external genital tissues, and gently spreads apart the labia majora in order to visualize the hymen. The examiner also may apply firm lateral outward traction to the child's buttocks to view the anal opening. When cultures are indicated, a sterile, cotton-- tipped swab is inserted into the child's vagina or anal opening. Teenage girls occasionally require a pelvic exam involving the insertion of a speculum into the vagina. Older girls also may be asked to provide a urine sample to test for pregnancy. In general, the check-up is not painful; some children, however, report mild discomfort when the examiner touches their genital and anal areas.

The benefits of colposcopy, which have been widely recognized, include the facilitation of microtrauma identification, the virtual elimination of the need for medical reexamination, increased opportunities for peer review and consultation, and the accumulation of knowledge about normal and abnormal pediatric genitalia (Hobbs & Wynne, 1996). From a psychosocial perspective, colposcopy offers reassurance about the health, healing, or intactness of children's bodies (Sgroi, Porter, & Blick, 1982). Nevertheless, the pediatric anogenital exam constitutes only one piece of the investigation and typically yields normal physical findings even in substantiated cases of abuse (Adams, Harper, Knudson, & Revilla, 1994). Accordingly, individuals who recommend, prepare, perform, and accompany children to the exam are obligated to minimize its potential for harm. Efforts to do so may safeguard children's and adult guardians' exam experiences, enhance professionals' ability to detect signs of injury or infection, facilitate further disclosures of abuse, reduce the need for subsequent exams, and avoid the added risk and expense associated with the administration of sedative medications.

The existing literature on pediatric anogenital examinations shows that children exhibit a broad array of responses to this medical procedure. Empirical studies generally find that children experience mild and transient exam distress (Lazebnik et al., 1994; Steward, Schmitz, Steward, Joye, & Reinhart, 1995). Case studies, by contrast, suggest that some children experience the exam as a traumatic event (Berson, Herman-Giddens, & Frothingham, 1993; Lawson, 1990). In response to such findings, protocols and suggestions have emerged for preparing survivors of child sexual abuse for a potentially retraumatizing medical procedure (Lawson).

Adult guardians' exam experiences have received far less empirical study. One investigation (Steward et al., 1995) found that mothers reported elevated levels of pre-exam distress that did not lessen upon the exam's completion. Another study (Waibel-Duncan & Sanger, 1999) reported that most adult guardians approached the pediatric anogenital exam with limited exam knowledge. These same adults reported the desire to play a more active role in educating their children about the impending medical procedure; however, they cited the following impediments: insufficient exam information, emotional distress, and the inability to translate the information in a developmentally appropriate way. Continued exploration of adults' exam experiences is supported by research documenting the role of maternal support in children's adjustment following abuse disclosures (Deblinger, Steer, & Lippman, 1999).

On reviewing the available literature on the emotional consequences of the pediatric anogenital exam, Britton (1998) and Dubowitz (1998) have called for more sensitive observations of children's exam responses. In response to this challenge, the present study explored what children and their supportive adult guardians bring to the exam in terms of their anticipatory worries. Although descriptive data exist on the medical fears of children who are well (Aho & Erickson, 1985; Broome & Hellier, 1987), chronically ill, acutely ill, hospitalized, and emotionally disturbed (Hart & Bossert, 1994; Wilson & Yorker, 1996), little is known about the specific medical fears of children who may have been sexually abused and their supportive adult guardians. Clearly, children who have been sexually abused are vulnerable to a number of physical conditions (e.g., HIV/AIDS and other sexually transmitted diseases, pregnancy, scars or disfigurement, encopresis/enuresis, psychosomatic complaints) that warrant timely medical evaluation and treatment. Information from this study is intended to facilitate professionals' efforts to effectively and empathically prepare individuals for medical encounters.

Given that all medical procedures elicit some level of worry due to their inherent challenges to individuals' physical integrity, psychological well-being, and support networks, study participants were expected to report moderate levels of concern about specific aspects of the pediatric anogenital exam. In addition, abuse experiences and psychological sequelae were expected to influence the nature and intensity of individuals' selfreported anticipatory exam worries.

Although a recent review of the research on abuse sequelae suggested that child sexual abuse is not associated with specific symptoms or a conspicuous syndrome in a majority of survivors (Kendall-Tackett, Williams, & Finkelhor, 1993), certain abuse outcomes have been identified in a substantial minority of survivors (Briere, 1992). Specifically, children who experience abuse may be at increased risk for post-traumatic stress, cognitive distortions, altered emotionality (e.g., anxiety or depression), and dissociation. More specifically, Janoff-Bulman (1992) suggested that abuse experiences may profoundly disrupt individuals' assumptions about the world's meaningfulness, the self's worth, and other's benevolence, leaving survivors to question the purpose and/or safety of subsequent events, their competence to deal with future stressful encounters, and the trustworthiness of others. In addition, Finkelhor and Browne (1985) have described four "traumagenic dynamics" associated with child sexual abuse. Specifically, feelings of powerlessness, betrayal, stigmatization, and sexual traumatization may negatively impact children's and adult guardians' interpretations of subsequent experiences such as the pediatric anogenital exam. Based on the broader pediatric literature and extensive clinical observations of the pediatric anogenital exam, younger children and children without prior exam experience were expected to report higher levels of anticipatory worry compared to their older and more experienced counterparts. Similarly, adult guardians who accompanied younger and less experienced children were expected to show the same pattern of concerns.

Methods

Participants

Participants included 47 girls ages 8 to 14 (mean = 11.57, SD = 2.14) and their adult guardians who were consecutively referred to a metropolitan outpatient clinic specializing in pediatric anogenital exams following allegations of sexual abuse. Exclusion criteria included individuals in a state of acute crisis, people with cognitive impairment, children accompanied by adult caregivers who were not their legal guardians, and individuals who did not read or speak English.

Seventy-four percent of the child participants were white; 26% were African American. Ninety-two percent of the children had made disclosures of sexual abuse prior to the clinic visit; 23% of the children approached the current medical encounter with prior anogenital exam experience. Eighty-nine percent of the adult guardians were maternal figures (biological or stepmother, aunt, or grandmother); 11% were paternal figures (biological or stepfather). Thirty-two percent of the alleged perpetrators were either the child's biological or stepfather; 26% were related to the child (brother, uncle, grandfather, or cousin); 38% had no familial relation to the child (mother's boyfriend, neighbor, adult, or peer acquaintance); and 4% were of unknown relation to the child. Thirteen eligible children and their adult guardians opted not to participate in the study. No demographic differences were found between participants and nonparticipants.

Measure

Participants' anticipatory worries were assessed by nine items representing common exam concerns. Items were selected through prior research (Waibel-Duncan & Sanger, 1999) and extensive observations by the clinic's medical and psychosocial teams. Situational concerns focused on the exam's potential painfulness, invasiveness, and cognitive incongruence. Interpersonal concerns focused on respondents' perception of whether their child or adult guardian would be able to emotionally tolerate the exam, not knowing the medical professional, and not knowing who else might have access to the exam's findings. Intrapersonal concerns focused on whether the child's body was healthy and the long-term physical and emotional impact of the exam.

Participants were asked to rate each item on a scale from 1 (not at all) to 5 (most) to indicate their current level of worry about specific aspects of the impending medical encounter. Participants also had the option of writing and rating an additional exam worry.

Procedure

On arrival at the clinic, a psychosocial professional screened children and adult guardians to evaluate their level of acute crisis and literacy. Prospective adult participants were asked for their written informed consent and permission for their children to participate. Next, children were asked for their written informed assent. As per the standard clinic protocol, adult guardians completed an intake questionnaire (15-20 minutes) regarding the nature of the current allegations, as well as the child's psychosocial and medical histories. Then, adult and child participants completed the brief (5-minute) study questionnaire. Participants were monitored by a psychosocial professional and encouraged to work independently Next, adults and children (age 5 and older) were interviewed separately to clarify children's medical and social histories and to gain any additional information necessary for medical diagnosis and treatment.

According to the clinic's standard protocol, investigative interviews were conducted away from the clinic by a forensic interviewer prior to the medical evaluation. In preparation for the medical procedure, clinic professionals addressed children's worries about their bodies and their health in general, inquired about the types of sexual contact they had experienced, answered children's and adults' questions about the check-up, provided sensory and procedural information, and addressed common exam misconceptions. In addition, professionals normalized the exam experience as an important part of protecting children who may have been touched inappropriately, emphasized the purpose of the exam as an opportunity to make sure the child's body was healthy, and explicitly distinguished the impending medical encounter from prior abuse experiences. Children also received a tour of the exam room and the opportunity to decide who, if anyone, they would like to accompany them during the exam.

Results

Anticipatory Exam Worries

Table 1 shows the percentage of participants who reported a relatively high level of worry about each exam concern (i.e., scores of 4 [a lot] or 5 [most]). Individual item analyses showed that a substantial proportion of the study's participants reported a relatively high level of concern about specific aspects of the exam. More than one third of the children, for example, reported a relatively high level of worry about their lack of exam information, not knowing who would be performing the exam, someone looking at or touching their anogenital area, and their current physical health status. The majority of adults reported a relatively high level of concern about their children's physical health status and their lack of exam knowledge. In addition, more than one third of adults reported a relatively high level of concern about their children's exam distress and the exam's potential painfulness.

Effects of Age and Prior Anogenital Exam Experience

Child's age was positively correlated with children's concerns about not knowing who would be performing the exam (r [38] = .439, p

Correlational analyses showed that previous anogenital exam experience was not related to either children's or adults' reports of elevated concern on any of the worry items.

Discussion

Consistent with previous investigations (Steward et al., 1995; Waibel-Duncan & Sanger, 1999), data from the present study suggested that individuals were not psychologically prepared for the pediatric anogenital exam. Specifically, more than one third of the child participants and more than half the adult respondents reported a relatively high level of concern about having limited exam knowledge. Lacking adequate exam information, children's and adults' mental representations of the relatively novel exam were likely influenced by salient memories of previous medical experiences (e.g., immunizations and annual pelvic exams, respectively). In fact, nearly one third of children and more than 40% of adults reported relatively high levels of worry about the exam's potential painfulness. In light of these common misconceptions, it was not surprising that child's age was negatively correlated with adults' level of worry about the exam's potential painfulness. Contrary to expectation, however, demystifying the medical event through prior anogenital exam experience had no apparent effect on any of the anticipatory exam concerns. Instead, the data suggest the importance of routinely and universally delivering information about the sensory, procedural, and temporal aspects of the exam.

Given that the majority of children were allegedly perpetrated against and betrayed by people known to them, professionals are encouraged to recognize and address individuals' potentially impaired judgment of others' trustworthiness. In fact, more than 40% of the children reported relatively high levels of worry about not knowing the person who would be performing the medical examination. In terms of other interpersonal concerns, abuse survivors who approached the pediatric anogenital exam were expected to fear further stigmatization, family disruption, or personal harm from perpetrator retaliation. Accordingly, they were expected to have concerns about the confidentiality of the exam's occurrence and findings. Data from the present study reflected this concern, as approximately 30% of child participants reported a relatively high level worry about this issue.

To counter concerns related to interpersonal aspects of the exam, professionals are encouraged to establish rapport prior to encountering individuals in the exam room. In our clinic, there is a large fish tank in the waiting area that staff members visit frequently to feed and look after the fish. Such impromptu visits afford children and adults the opportunity to become acquainted with the staff in a more neutral setting. In addition, medical (rather than psychosocial) professionals prepare adolescents for the exam, a practice that is consistent with the finding that child age was positively correlated with children's level of concern about the medical staff's unfamiliarity.

More than 40% of child participants and more than one third of adult respondents reported elevated worry about someone inspecting their (child's) anogenital area. Although concern about maintaining privacy is one of children's universal medical fears (Aho & Erickson, 1985), abuse survivors and their guardians may experience a heightened sensitivity to events that threaten their personal boundaries. Accordingly, techniques that acknowledge and honor physical boundaries are strongly recommended. In our clinic, for example, tours of the exam room are conducted while children are still in their street clothes. During this exploratory time, children are encouraged to look through the colposcope and to experience the distance of the instrument from their bodies in both the sitting-up and lying-down positions. During the exam, medical professionals gradually introduce more intrusive aspects of the exam by demonstrating genital palpation on their own cheeks and then (with permission) on the child's cheeks. Other strategies that acknowledge and protect physical boundaries include providing a large sheet for children to cover their legs, face, or whole body; beginning the evaluation with a less threatening and more familiar physical exam; and using tokens to offer children a set number of time-limited "breaks" at their request.

Almost half the adult participants reported a relatively high level of worry about children's distress during the impending medical encounter. They further documented this concern in written comments such as "I am worried about whether I can see her through this" and "I am worried about whether this check-up will hurt her mentally." One adult feared "my child will be angry with me for putting her through this [exam]." Normalizing adults' concerns for children's well-being, informing adults of research suggesting that most children experience mild and transient exam distress, and advising adults about the staff's efforts to assist children prior to and during the exam may help reduce this common exam concern. In contrast to adults' concern about children's exam distress, relatively few children reported a high degree of worry about their guardians' potential exam distress. This finding suggested that children maintained some level of confidence in their guardians' emotional and physical availability. Collectively, these data suggest the need to prepare both children and adults for the impending medical procedure and to allow children to decide who, if anyone, they want to accompany them during the exam.

In terms of intrapersonal exam worries, 25% of adult guardians and 20% of children reported relatively high concerns about the exam's potential physical impact. These concerns generally involved misconceptions about the exam's invasiveness and, more specifically, physical disfigurement secondary to speculum insertion. In addition, more than one third of children and more than half of adults reported relatively high concerns about children's current physical health status. Although concern about the body's physical integrity represents one of children's universal medical fears (Aho & Erickson, 1985), participants' worries centered on the specific issues of scarring, HI-BV/AIDS, pregnancy, and sexually transmitted diseases. In addition, child age was positively correlated with children's concern about their current physical health status. This finding may reflect developmental fears related to physical disfigurement, loss of physical attractiveness, and self-dysregulation, as well as more sophisticated conceptualizations of illness's impact on quality-of-life (Bibace & Walsh, 1981). Such intrapersonal concerns may be palliated by emphasizing that it's normal to find no physical evidence of sexual abuse and by reiterating that the main purpose of the exam is to offer reassurance about the health, healing, and intactness of children's bodies.

Conclusion

Data from the present study reaffirm the need to prepare children and supportive adult guardians for the pediatric anogenital exam. The data also enhance professionals' understanding of the individuals who approach this relatively novel medical procedure in the context of sexual abuse allegations. Study limitations include the restricted range of exam experiences that were available for investigation. Future research should include a broader spectrum of settings (e.g., emergency rooms and pediatricians' offices) and circumstances (e.g., no abuse allegations and allegations of acute abuse). In addition, research on how exam worries vary as a function of the child's age, race, gender, and the nature of the alleged abuse will provide useful information for the refinement of existing preparatory protocols. Further, an investigation of how exam worries change as a function of specific preparatory protocols may be accomplished through a multimethod and multirater approach. The author's ongoing program of research explores how exam worries influence highorder cognitive appraisals and translate into affective exam experiences (Waibel-Duncan & Sandler, 2001). Collectively, such information is intended to support professionals' efforts to achieve the highest standards of excellence in patient and family care.

Acknowledgment. The author thanks the clinical and administrative staff at OUR KIDS Center in Nashville, TN, for their dedication to this project. Special thanks to Dr. Maureen Sanger (child clinical psychologist) for her editing comments in the manuscript's preparation, Carol Dozier (clinic coordinator) for her assistance in the data-collection phase of this study, as well as Sue Ross and Barbara Speller-Brown (pediatric nurse practitioners) for their clinical insights. The author also extends her appreciation to the children and adults who participated in this study by sharing their pre-exam experiences.

References

Adams, J.A., Harper, K., Knudson, S., & Revilla, J. (1994). Examination findings in legally confirmed child sexual abuse: It's normal to be normal. Pediatrics, 94, 310-317.

Aho, A.C., & Erickson, M.T. (1985). Effects of grade, gender, and hospitalization on children's medical fears. Journal of Developmental and Behavioral Pediatrics, 6, 146-153.

Berson, N.L., Herman-Giddens, M.E., & Frothingham, T.E. (1993). Children's perceptions of genital examinations during sexual abuse evaluations. Child Welfare, LY_XII(1), 41 - 49.

Bibace, R., & Walsh, M. (1981). New directions for child development: Children's conceptions of health, illness, and bodily functions. San Francisco: Jossey Bass.

Briere, J.J (1992). Child abuse trauma: Theory and treatment of the lasting effects. Newbury Park, CA: Sage.

Britton, H. (1998). Emotional impact of the medical examination for child sexual abuse. Child Abuse and Neglect, 22, 573-579.

Broome, M.E., & Hellier, A. (1987). School-age children's fears of medical experiences. Issues in Comprehensive Pediatric Nursing, 10, 77-86.

Deblinger, E., Steer, R., & Lippman, J. (1999). Maternal factors associated with sexually abused children's psychological adjustment. Child Maltreatment, 4,13-20.

Dubowitz, H. (1998). Children's responses to the medical evaluation for child sexual abuse. Child Abuse and Neglect, 22,581-584.

Finkelhor, D., & Browne, A. (1985). The traumatic impact of child sexual abuse: A conceptualization. American Journal of Orthopsychiatry, 55,530-541.

Hart, D., & Bossert, E. (1994). Self-reported fears of hospitalized schoolage children. Journal of Pediatric Nursing, 9,83-90.

Hobbs, C., & Wynne, J. (1996). Use of the colposcope in examination for sexual abuse. Archives of Disease in Childhood, 75,539-542.

Janoff-Bulman, R. (1992). Shattered assumptions: Toward a nezu psychology of trauma. New York: The Free Press.

Kendall-Tackett, Williams, L.M., & Finkelhor, D. (1993). Impact of sexual abuse on children: A review and synthesis of recent empirical studies. Psychological Bulletin, 113(1),164-180.

Lawson, L. (1990). Preparing sexually abused girls for genital evaluations. Issues in Comprehensive Pediatric Nursing, 13,155-164.

Lazebnik, R., Zimet, G.D., Ebert, J., Anglin, TM., Williams, P, Bunch, D.L., & Krowchuk, DT (1994). How children perceive the medical evaluation for suspected sexual abuse. Child Abuse and Neglect, 18, 739 - 745.

Sgroi, S., Porter, F, & Blick, L. (1982). Validation of child sexual abuse. In S. Sgroi (Ed.), Handbook of clinical intervention in child sexual abuse (pp. 59-79). Lexington, MA: Lexington Books.

Steward, M.S., Schmitz, M., Steward, D.S., Joye, N.R., & Reinhart, M. (1995). Children's anticipation of and response to colposcopic examination. Child Abuse and Neglect, 19,997-1005.

Waibel-Duncan, M.K., & Sandler, H. (2001). Pediatric anogenital exam: A theory driven exploration of anticipatory appraisals and affects. Child Maltreatment, 6, 50-58.

Waibel-Duncan, M.K., & Sanger, M. (1999). Understanding and reacting to the anogenital exam: Implications for patient preparation. Child Abuse and Neglect, 23, 281-286.

Wilson, A.H., & Yorker, B. (1996). Fears of medical events among school-age children with emotional disorders, parents, and health care providers. Issues in Mental Health Nursing, 18,57-71.

Mary Katherine Waibel-Duncan, PhD, is Assistant Professor of Psychology, Peabody College of Vanderbilt University, Bloomsburg University of Pennsylvania, Bloomsburg, PA.

Author contact: mkwdunc@aol.com, with a copy to the Editor:

Poster@uta.edu

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