Over the past decade and a half there has been a standardization in the use of the colposcope for photo documentation in the evaluation of child sexual abuse cases. The use of colposcopy has become the standard of care for pre-adolescent children, and medical professionals recognize the added specific benefits of video colposcopy for the evaluation of adolescent and adult sexual assault victims.

It is important for all health care professionals to continue to emphasize that a thorough history is the most important part of any medical evaluation. However, we also need to have a sophisticated understanding of the significant medical-clinical evidence of sexual assault. There are primarily two types of medical evidence: 1) Laboratory (forensic evidence and sexually transmitted diseases); and 2) Clinical, or the documentation of traumatic and psychological injuries.

Clearly, laboratory evidence can be definitive when there is evidence of ejaculation. It has become more important, however, to provide the clinical documentation of trauma associated with assault, as many cases are presented without forensic evidence or with legal strategies claiming that the "intercourse" was consensual. In recent years there has been an increased understanding of the significance of medical (clinical) findings in sexual assault. Researchers have reached a consensus on those clinical findings of trauma and variants of normal and non-specific changes.

Video Colposcopy
Most of the medical advances and research in the field of child sexual abuse and sexual assault have relied heavily on the use of photo documentation. The most widely accepted means of photo documentation is now the colposcope. With the addition of video, computer technology, and telemedicine, it is now the basis for international research and peer review. During the past decade photographs have been used to clarify terminology, improve accuracy of data, and promote regional and national peer review. Most recently, telemedicine gives remote sites access to the same expert opinions available in specialized urban centers.

The primary benefit of colposcopy to the victim of sexual assault is the single examination. This examination, which has been appropriately documented through colposcopy, can then be reviewed with experts and provided to the legal system, avoiding the need for numerous examinations and/or examiners. Currently, most sexual assault research projects require photographic documentation of all findings to ensure that inter-observer reliability is maintained and that the conclusions meet the accepted standards of diagnosis.

Video colposcopy adds an additional dimension. The examination can be virtually recreated via videotape and is particularly important when evaluating the adolescent or adult patient. In these patients the estrogenized hymen tends to be more dynamic and moves during the examination. Video documentation allows the examiner to evaluate all of the folds and clefts which may be missed during still photography. As an added benefit, video colposcopy gives teaching programs the ability to instruct through closed circuit video, rather than having numerous evaluators in the room during the examination.

With the increased reliance on nurse specialists or forensic nurses, the video documentation allows for the physician back-up to review and participate in both diagnosis and treatment, and the legal processes. This collaboration improves the quality of the evaluation for the patient and the system, while giving the patient access to a medical setting staffed by caring professionals.

The primary use of photographic documentation by the legal system has been in the substitution of photographs for re-examination. Defense and court-appointed experts can review prior evaluations easily without additional trauma to the patient. This use of colposcopy in the diagnosis of sexual abuse of children and adult victims of sexual assault has been upheld by the appellate court of California (Mendibles) and its use is described as being non-experimental.

Summary
As we continue to build a system which can accurately and appropriately respond to the challenges of sexual assault, photo documentation will play an important role. Listening to the patient and performing meticulous evidence collection are critical. Just as important is the careful delineation of all trauma, providing a plan for appropriate treatment, and referral for consistent medical and mental health follow-up. Video colposcopy is a major tool in providing the best of care to all victims of sexual assault. It allows us to protect the victim, educate med-ical professionals, provide case peer review, and guarantee appropriate, expert evidence to the legal system. Excellence and accountability make for the highest quality treatment plans and appropriate interventions and investigations by the social and legal systems.

Video colposcopy will not replace the meticulous, sensitive, well-trained professional, but it can bring the best of documentation and accountability to a diagnosis which must be made accurately and scientifically for the protection of both the victim and the system. This is truly a case where "a picture is worth a thousand words."

CIRCON CRYOMEDICS®
MM-6000 Colposcope

Selected Bibliography

1. Heger AH, Emans SJ: Evaluation of the Sexually Abused Child; Textbook and Atlas, New York: Oxford University Press, 1992.
2. Muram D: "Child sexual abuse - genital tract findings in prepubertal girls: comparison of colposcopic and unaided examinations." Am J Obstet Gynecol 1989; 160:333-335.
3. Norvell MK, Benrubi GI, Thompson RJ: "Investigation of microtrauma after sexual intercourse." J Reprod Med 1984, 29:269-271.
4. Ricci L: "Medical forensic photography of the sexually abused child." Child Abuse Neglect 1998, 12:305-310.
5. Slaughter L, Brown C: "Colposcopy to establish physical findings in rape victims." Am J Obstet Gynecol 1992, 16(1)83-86.
6. Teixeira, RG: "Hymenal colposcopic examination in sexual offenses." Am J Forensic Med Pathol 1981, 2:209-214.
7. Woodling BA, Heger A: "The use of the colposcope in the diagnosis of sexual abuse in the pediatric age group." Child Abuse Neglect 1986, 10:111-114.

Dr. Heger is executive director of the Violence Intervention Program at the Los Angeles County and University of Southern California Medical Center where she is also an associate professor of clinical pediatrics. In 1984 Dr. Heger founded The Center for the Vulnerable Child for the evaluation of child abuse. Dr. Heger is an internationally recognized expert on the medical diagnosis of child abuse and neglect and sexual assault in all ages. She pioneered the use of photo documentation techniques while developing standards for the medical evaluation of child and adolescent victims of sexual assault which have become the international standards of care.