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MEDICO-LEGAL REPOR]

PATIENT'S NAME ANGELIE ROSE M. DELOS REYES AGEI 14 IOOS 7125t241 SEX ;

PATIENT'S ADDRESS: Mzurayon, Bangui, Ilocos Norte HospitalNo. 72 101

CIVIL STATUS Sinsle loccupRr-lot't I None Fil pino
NATIONALITY
PNP PLACE, TIME & DA'fh; Mariano Marcos Memorial Hospital & MC
REQUESTING PARTY
OF EXAMINATION March 16.2016 (0 10:35 PM
7J ACUTE EVIDENTIARY EXAMINATION (WithiN ?2 HOUrS Of iNCidCNt) f--'l lNon-acute examination
FINDINCS
GENERAL PHYSICAL EXAMINATION
HEIGHT 154 crn I WEIGHT 50.5 kes TANNEII STAGE ltl
corlsclous, coherent
GENERAL SURVEY

MENTAL STATUS awake, aleft, oriented as to tirne and place

PERTINENT PFIYSICAI, (+)abrasion, rnultiple:right and left legs, face, right and left extremities
FINDINCS/PHYSICAL
INJURIES
ANO.GENITAL BXAMINATION
EXTERNAL GHNITALIA
with soilparlicles and dry grass
URETHRA AND
PERIURETHRAL AREA with laceration 0.5 cm at left periurethral area
PERIHYMENAL AREA
AND FOSSA
NAVICULARIS with 1 cm laceration with active bleeding
HYMEN redundarrt lrynen
PERINEUM (+) soil particles
DISCHARCE witlr rnucoid whitish discharge
IE AND cervix long closed, uterus small, (-)CMT , (-) AMT
SPECI"JI-UM EXAM cervix pinkish, (+) mucoid disclrarges
ANAL EXAMINATION not done
REMARKS
FORENSIC EVIDENCL,
COLLECT'ED
LABORATOR.Y GS KOH of vagirial discharge- see attached result Urinalysis - see attached result
EXAMiNATION (EXAM CBC - see attached result RPR, HbsAg - see attached result
AND RESUI,'| ) Sperm Identification - see attached result
TMPRF"SSIONS
Disclosure of sexual abuse
Definitive findings of prcvious blunt injut:'; G0 Day l2 o{men

NAME AND SICNATURE OF EXAMINER:

RACHEL D

LAY. MD
 RepuUkofth€phi[ppin€s ,A
Dcp.rtmnt of Health I
Csts of Hee{fi Dw.}op|rent . thcos
MARIAI{O MARCOS HEUORIAT }IOSPTfAL & IIEDICAL CEiITER
gitx. {rcos ilorte
"PHIC Accredltad H€stth Cirr proyider.
Ttu||k {m:0?-t92-!lrt4; Fax Sne: 07?-t9?-!li3

GYI{SCOIOGIC CYTOTOGY RSPORT

Patient Name : DELCIS RfyES, ANGEHE ROSE MTRANDA

# ; 721101
Patient lD AgelGender: 14 / TEMATE Access No. : RP 1S0016
Physician : Jalog, Rachel Room No. i ER/ER Received : 16-Mar,Z016 11:56 pM
Address : I BANGUI. ttOCOS NSRTE Adm, Date i Released : 1?-Mar-2016 Z:15 pM

SPEClilEt{ ADEQUACy: Satisfactory for evaluation

IVTENPNEIANON / RESULT
Negative for Intra-epithelial Lesion or Malignancy

R€marks:
Itegativa for sperm cells.

nq

CERTFIED IRI'T PilOTSCOPY

OF CGPY $il FILE'
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t.

Sexual Abuse: Signs and Symptoms

originally placed online by the Harvard med students -- Thank vou!

* Mect ical I ud iC-;!f *rl

* Ps'r ch gsot' i4! i rld lqilt tl_rl

Table. Aoril2003: Ph
Used with permission of Joyce Adams, MD

Key point to remember in evaluating children and adolescents who may have been sexuallv
abused:
As many as 85-957o of children who give a clear history of sexual abuse may have normal
or nonspecific physical examinationso due to healing of trauma or acts that do not result in
trauma.

Female Genitalia Anus Penis/Scrotum Other

Class I Normal or Class 1 Normal or Class I Normal or Class 1 Not related to
Un"etatffiffi* Unrelated to Abuse un."htli-IoEG" abuse:

Found in newborns: *Tag at 6 o'clock from *Circle of brown rCandida infections

*Periurethral or redundant perineal .pigment around shaft *Strep infections
,vestibular bands raphe of penis from healed rUrinary tract
*Hymenal tags cThickening of circumcision infections
rHymenal bump or perineal raphe *Raised, dark line *Vaginitis caused by
mound *Blue tint from along penis/scrotum enteric or respiratory
*Linea vestibularis underlying veins (median raphe) organisms
*Hymenal cleft/notch *Gardnerella vaginalis
in the anterior Normal variants: cultured from vagina,
:(superior) half of *Diastasis ani
the in the absence of any
hymenal rim, on or *Perianal skin tag other signs of bacterial
above the 3 o'clock *Increased perianal vaginosis
and 9 o'clock line, skin pigmentation
,patient supine *Anal dilation with Also, conditions such
r*Estrogen changes stool present
4i; as urethral prolapse,
cVenous congestion, lichen sclerosis, genital
,Normal variants: or venous pooling, in hemangiomas, Crohn's
*Septate hymen perianal tissues i:" ! Disease, and Bechet's
*Failure of midline Disease may be
,
fu sion/perineal groove mistaken for abuse.
Class 2 Nonsoecific Class 2 Nonspecific Class 2 Nonsoecific Class 2 Nonspecific:
May be transmitted
Findings that may be *Erythema (redness) rErythema of penis, by sexual or
the result of sexual of the perianal tissues lower abdomen or nonsexual means:
abuse, depending on *Anal fissures inner thighs
the timing of the *Anal dilation without *Edema of rHerpes type I or II in
examination with stool visible penis/scrotum a child who requires
respect to the abuse, *Superficial abrasions (These may result from caretaker assistance
but which also may be of the perianal skin self-manipulation, poor with toileting or
due to other causes. *Bruises on the hygiene, contact hygiene, or who may
buttocks irritation/infl ammation. have self-innoculated
*Erythema (redness) *Vesicles or ulcers in or infection) from an oral lesion
of the vestibule or the anal area or on the cSuperficial abrasions rBacterial vaginosis in
increased vascularity buttocks on the penis/scrotum a child or adolescent
 ; ("dilatation of existing *Bleeding from the *Warty lesions or *Any STD (including
blood vessels") of anus tii.j_i_ijr1-11 vesicular lesions on the HPV or genital wards)
'vestibule penislscrotum in an infant who may
rrSuperficial abrasions have acquired it
,of the labia or perinatally i!1
,posterior fourchette
rShallow notches in
rthe posterior rim of
extending
'hymen 50Yo or less of
,through
Ithe width ofthe
rim
'hymenal
*"Narrod'rim of
,hymen measuring l-2
,mm wide
*.Labial adhesion
,rVaginal discharge
,rVesicular lesions or
:ulcers in the genital
,area
;*Genital warts in a
,child
,*Blood on underwear
'*"Vaginal" bleeding
t(Found in both abused
;and non-abused
,
children/adolescents)
,iii. iii. ir'.:.:t)

Class 3 Concernins Class 3 Concerning Class 3 Concernins Class 3 Concerning

;for Ahuse
rFindings that have
,been noted in children
with documented
,abuse, and may be
:suspicious for abuse,
rbut for which
,
insuffi cient data exists
to indicate that abuse
ris the only cause.
.Acute trauma'
,suspect sexual abuse:
,rAcute lacerations or
,bruising of labia,
,fossa, posterior
,fourchette or
;perihymenal tissues
;*Bruises or bites to
iupper or inner thighs
,near genitalia
r* Sucker/trickey marks
ron inner thighs near
,senitalia
for Abuse for Abuse for Abuse: Sexual
transmission is likelv
Acute trauma - Acute trauma - cause of infection:
suspect sexual abuse: suspect physical or
rMarked bruising and sexual abuse: rHerpes type I or Il
edema ofthe perianal *Banding of penis lesions in the genital
tissues. as with child's hair or area in a child who has
distinguished from otner objects (thts may no oral lesions and
venous pooling be accidental in requires no assistance
infants, from hair of a with toileting or
Possible residual caretaker) hygiene
from trauma: *Bite or pinch marks rTrichomonas
rPerianal scar (may be on penis, scrotum, or infection diagnosed by
due to healed fissure inner thighs near wet mount preparatlon
from Crohn's Disease genitalia or culture of vaginal
or from surgery) *Sucker/hickey marks secretions
on inner thighs near *HPV infection in a
genitalia child in whom
perinatal transmission
is considered unlikely
{\'rl)
 iPossible healed ;

;injuries from abuse:

cscar of the posterior
fourchette
rrHymenal notch/cleft
I

extenomg through
,more than 50olo of the
iposterior (inferior) or I

lateral portion of the ,

,hymenal rim

Class 4 Clear :Class

4 Clear ,Class 4 Clear
jevidence of blunt revidence penetration I

itrvidence: Sexual
lforce or penetrating rbevond the anal jabuselcontact is
jtrauma to or beyond ;snhincter: certaln:
the hvmen:
i
i
rPerianal lacerations i*Pregnancy
iFindings that can have extending deep to the i*Sperm or semen
jno explanation other ,external inal Jphincter ifound in or on child's
than trauma to the ull :body
hymen or vaginal ,*Video or photo
tissues. :documentation of child
rbeing abused
Acute trauma: ,*Confirmed positive
rPartial or complete
lgenital, anal or
tear of the hymen I
pharyngeal cultures for
*Ecchvmosis :Neisseria gonorrhea
(bruising) on the ;*Positive cultures (not
hymen trapid antigen tests)
;rVaginal laceration lfrom genital or anal
;area for Chlamydia
Ilealed trauma: rtrachomitis
,*Hymenal transection ,*Positive serology for
:(healed), defined as an
rsyphilis or HIV, if
area where the hymen ,perinatal or blood
has been torn through, itransmission has been
ito the base, so there is rruled out (r"il)
,no hymenal tissue '

'
remaining between the
vaginal wall and the :

fossa or vestibular
,wall.n iii I This finding
has also been referred
to as a "complete
,cleft" in adolescent
'and young adult
1women.15; i

:rWide areas in the

lposterior (inferior) half i

qof the hymenal rim f

with an absence of
:hymenal tissue,
:extending to the base
,

jofthe hymen, which is ,

confirmed using
additional examination
;technique (swab, iof.V i
rcatheter, prone knee-
i

chest position).

This table was developed from multiple sources, including published classification scales
authored by David Murarn, MD and Joyce Adams, MD. Penis and scrotum classification and
"othe/'by Charles Johnson, MD.

Adapted from:
Muram D. Classification of genital findings in prepubertal girls who are victims of sexual abuse.
Adolesc Pediatr Gynecol 1988; I : l5 l.
Adams JA. Evolution g{aclassification scale. Medical evaluation of suspected child sexual
abuse Child Maltreatment 200I;6:3 l-36.
Johnson CF. Is it normal or not? SCAN 2001;13:4-5.

Tqp

Psychosocial Indicators of Sexual Abuse

* Serualized Belial iors

t.Nonspecigc

The following factors may influence the intensity and type of reaction a child has to the
experience of sexual abuse (although some important issues related to any one child's experience
may not be included in this list):

*'Identity of p erpetrator
*,Child's age
tChild's developmental status, including whether or not the child has any developmental
disabilities
*fiistory of prior, or concurrent maltreatment, trauma or stress
.*Relationship with alleged perpetrator
tDuration (time span) of the abuse
'*Circumstances/context
of the abuse (i.e. has the child been afraid, embarrassed, etc?)
$Type and intensity of abuse or neglect
*Family, social and community support
*Child's coping strategies, and generality personal characteristics (i.e. temperament)

A child's reactions may involve behaviors that can be observed by other people, or may simply
involve the child's innermost thoughts and/or subjective emotional feelings. Some of the
reactions to sexual abuse can be similar across age groups, while other reactions may be more
common in younger or in older children. In general, it may be diffrcult to differentiate children
who have been sexually abused from children who have experienced other kinds of stressful
experiences. It is important to remember that research in the area of child maltreatment suggests
that many abused children do not exhibit any obvious reactions to sexual abuse. Therefore, if a
child is not exhibiting concerning behaviors, but you have reason to suspect sexual abuse (for
instance, if the child has been exposed to a known sexual offender), it is strongly recommended
that you consult a professional with expertise in the area of child maltreatment for guidance.

The following list includes general signs and symptoms that may sometimes be observed in
sexually abused children. When reviewing this list, it is very important to remember that fears
and behavioral difficulties are commonly associated with normal child development. Many of
the following are concerning only when behavioral changes are extreme or occur suddenly. If
you have concerns, it is often helpful to consult a professional with expertise in this area.
Sexualized Behaviors

While there is no one symptom which is diagnostic of sexual abuse, with the exception of
pregnancy or a sexually transmitted disease in a non-sexually active child or adolesient, the
literature indicates that the symptoms most commonly associated with sexual abuse are
sexualized behaviors, particularly trying to engage other children in sexual behaviors, and
indicators of age-inappropriate sexual knowledgi. However, it is extremely important to
understand that many children who have been sexually abused do not exhibit iexualized
behaviors. It is equally important to understand that children who have never been sexuallv
abused may exhibit sexual behaviors.lg

Risk Factors for Sexualized Behaviors

As a general comment, it is important to note that there are numerous factors that may be
associated with age-inappropriate acting out sexually. The following life circumstances are
thought to increase the risk of children engaging in inappropriate sexual behaviors:

tsexual abuse
tiExposure to individuals (adults, adolescents or other children) known to have committed prior
sexual offenses
*tiving in a highly sexualized/over-stimulating atmosphere where personal boundaries are
lacking
,*.Exposure to adult/adolescent sexual intimacy
*Exposure to sexually explicit materials including printed materials, videotapes, or pornography
#tiving with needy adults who may turn to children to meet their emotional needs or unmet
needs for affection

Function of Sexualized Behaviors

The function of sexualized behaviors varies from child to child. Sexualized behaviors are thought
to serve the following functions:

#To decrease a child's anxiety, fear or overall distress; to reduce tension or other unpleasant
internal sensations
i*To retaliate or hurt others
i#To reflect re-experiencing behaviors consistent with reactions often noted in children who
have been sexually abused
tTo elicit an intense reaction from other children or adults
. To be motivated by needs of attention or power.
ffTo reflect natural curiosity at times, but be misinterpreted on occasion as deviant

Sometimes sexual behaviors in children may actually be age-appropriate and likely contribute to
normal and healthy sexual development. Sometimes children may not understand social
expectations, or that the sexualized behaviors are socially unacceptable.

Distinguishing Worrisome from Healthy Sexual Behaviors

A number of authors have written about sexualized behaviors in children. Friedrich has done
considerable research in this area and has begun to identify which sexual behaviors are most
likely to occur in boys and girls of different ages.(51 For instance, touching sexual parts (private
parts) at home is common for most children and usually not a worrisome behavior.

Toni Cavanaugh Johnson has identified characteristics that can help a parent or adult figure out if
a sexual behavior is cause for concern or is simply a normal part of growing up.(O However,
even if you think that a behavior is normal and unrelated to sexual abuse, it is often helpful to
discuss the behaviors with a professional who has expertise in this area if you have any concerns.

The following infbrmation has been adapted from the work of Toni Cavanaugh Johnson
regarding Natural and Healthy Sexual Behaviors exhibited by children. It is her view that
sexualized behaviors classified as natural and healthy represent an information gathering process.
It is important to note that children engaging in normative sexual behaviors are:

xof similar age, size and/or developmental status

nengaged in mutual sexual exploration
*likely to display a lighthearted emotional expression

Of further note is that the sexual behavior is:

*limited in time and frequency

* alanced by curiosity about other aspects of his/her life
*rmay result in embarrassment when discovered by someone else
*ceases (in the presence of adults) when children are instructed to stop engaging in the behaviors

Dr. Johnson has also identified Problematic Sexuol Behaviors in children. The list that follows is
not exhaustive which means that other characteristics that are not included on the list can also be
worrisome. Even worrisome behaviors do not mean that a child has been sexually abused.
However, if you are concerned about a child's sexual behavior, it is often a good idea to consult
a professional with expertise in this area. The following sexualized behaviors are thought to be
problematic:

ffisexual behaviors engaged in by children of different ages and./or developmental levels

#sexual behaviors which are significantly difiFerent thanthose of same age peers
f;llSexual behaviors that progress in frequenc5 intensity and irttrusiveness over time
iffisexual behaviors that include animals
ffisexual behaviors that are intended to inflict pain or hurt others
ffisexual behaviors that have been coerced by other children by the use of force, bribery,
manipulation or threats
fl*sexual behaviors that cause children to react with fear, anxiety, shame or guilt

Psychosocial Indicators of Sexual Abuse

Nonspecific Behaviors

Sexually abused children may exhibit a range of emotional or behavioral problems as a result of
their abuse experience. The type and degree of disturbance varies from child to child ranging
from no obvious reaction to very mild reactions to extreme behavior changes. According to one
published article, vp to 4U/o of sexually abused children are asymptomatic.gl This means that no
symptoms or concerning behaviors were observed. It is imponant to note that no single symptom
or behavioral profile can distinguish a maltreated child from his/her age-mates who have not
been maltreated. Most of the behaviors exhibited by abused or neglected children are often
associated with non-abuse related diffrculties or other types of trauma experienced by children.
Of the behaviors that may be seen in sexually abused children, most are also linked to extreme
stress reactions in children andlor general child trauma. That means that a child's behavioral
changes can cause concern and be quite alarming because he or she has been sexually abused,
but can also be caused by circumstances completely unrelated to child abuse.

The following behaviors are sometimes be seen in sexually children. They are significant when
they occur in conjunction with a child's disclosure and/or if the child has been exposed to a
known sexual offender. These symptoms and behaviors in and of themselves do not necessarily
indicate sexual abuse, but may be indicative of some other problem or trauma.

Behavioral Reactions:

ffiSleep distiurbances: night terrors; nightmares; trouble falling asleep; trouble stayng asleep or
sleeping alone.
#Changes in eating habits: compulsive or overeating; loss of appetite
tl -l-i

ffichanges in toileting habits including urinary or bowel accidents

Increased aggression: directed toward self (including suicide attempts) or others
ffiIncreased impulsivity and activity
ffiAcademic problems: distractibiliiy, concentration problems, lack of focus
l*Reluctance or refusal to go home or to other environments
flFasily startled; seems to be tense quite often; difliculty relaxing and calming down
ffiUnexplained fears of, or avoidance of, specific individuah, places, objects o.-r situations
ffi Separation anxieties. clinginess, school refu sal
I*Negative statements about oneself; a negative or pessimistic outlook
Low energy
fl*social withdrawal
*somatic/medical complaints: commonly include gastrointestinal complaints, headaches, pain
and general physical malaise
ffAntisocial acts, such as hurting animals, setting fires and stealing
ffiunning away from home

Cognitive Reactions:

*Inattentiveness
i*Disorientation
*Oaydreaming and fantasizing
ffiNegative thoughts about oneself,, related to low self-esteenq guilt embarrassment and self-
blame
f*Pessimism regarding the future and/or a difficulty imagining oneself in the future
ffiForgetfulness

Emotionql Reaetions:

Some emotional reactions can be associated with the behavioral and cognitive reactions
described above, as well as physiological changes that are more diflicult to observe (e.g.,
increased heart rate). Children who have been sexually abused or otherwise exposed to extreme
stress are often described as anxious, depressed, or as labile (having unusually strong mood
swings) and they may have difficulty calming down or soothing themselves when they are upset.
They can also appear to be very needy of adult attention, fearful of inciting adult displeasure,
and/or unusually suspicious or fearful in situations that might not cause discomfort in others.

Psychosocial Indicators of Sexual Abuse

Tgp

References:
(1) Massachusetts Department of Social Services. Investigation Training: Evidence and Indicators of Maltreatnent.
March2002.
(2) U.S. Deparnnent of Justice. Portable Guides to Investigating Child Abuse: Child Neglect and Munchausen
Syndrome by Proxy. September 1996.
(3) U.S. Depaffnent of Justice. Portable Guides to Investigating Child Abuse: Recognizing When a Child's h:dury or
Illness is Caused by Abuse. Link is now down. June 1996.
(4) Kendall-Tackett KA, Williams LIM, Finklehor D. hnpact of sexual abuse on children: a reyiew and rynthesis of
recent empirical studies. Psychol Bull, I 993; I 13 : 164-80.
(5) Friedrich WN, Fistrer J, Broughton D, Houston M, Shafran CR. Normative sexuat behavior in children: a
contemporary sample. Pediatrics, 1998; 10 1(4):E9.
(6) Cavanaugh Jobnson T. Understanding the sexual behaviors of young children Siecus Report, August/September.

Adams Classification Table Specific References:

(i) Berenson A, Heger A, Andrews S. Appearance of the hymen in newborns. Pediatrics, l99l; 87:458465 .
(ii) Berenson AI!, Heger AH, et al. Appearance of the h)'men in prepubertal girls. Pediatrics,1992;89:387-394.
(iii) McCarn J, Wells R, Simon M, Voris J. Genial findings in prepubertal girls selected for non-abuse: A
descriptive study. Pediatrigs, 1990; K:428439.
(iv) Heger AII Ticson I Guerraq L, et al. Apparance of the genitalia in grls selected for nonabuse: Review of
 .. \..xr:rwl;:.:j

prynal morphology and nmqecific finrlings. J Pediatr Adolesc Gynecol 2wJ2;15:27-35.

(v) BerensonAB' ChdohdR, wiemmClvl,Mshaw CO,Frie&iciwN,
craryrr. Acase-coruolsulyof
q{9-i9 chun|ges r€sultitrg from soilat ahse. Am J obstet G)mecol, 2000;lg2:izo-s:+.
(Yi) McCam, J, Voris J, Sinon M W€lls R Periaml finrtings iq pee$ert"t
cfrildnen sel€cfied for non-abuse: A
deccrigive strdy. Child Ahrse & Neglec! t9g9; 13:l?S193.
(vii) Cmters for Disease Control ad PnewNfion (CDC) OdOetines, MMWR" Vol. 51, lrlay re
2002.
http://ww*/-cdc. govlstd/treatmelrf/rrs l06.pdf
(viii) MccamJ' voris I SimonM Gwitalinjuriesresultingftom sorual abuse, Alongitudinal shrdy. pediatics,
1992;89:3O7417.
(ix) Mccam J, Voris J. P€rianal iqiuries resulting from se>nral abuse: A longindinal stgdy. pediatrics, 1993; 9l:390-
397.
(x) Emans SJ, lvoods E& Allred EN, Crace E. Hymenal firxlings in adolescent women: Impact
of tanrpon use rnd
mnsensual sCIrual activity. J pediatr,lg4; 125:153-160.
txi) Be'renson AB, Cna$y Jt. A longitdiml smdy of hymenal development fiom 3 to 9 y€flrs dage. J pedim
200},L4O:6M4O7.

Last Updated: June 2t 2003

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