3 July 2000

1. 8 Year Old with Vaginal Discharge
2. Did CPS Harm, Rather Than Protect This Child?
3. CPS (continued)
4. CPS (continued - 2)
5. Disclaimer

• Read Questions & Answers in Another Column

8 Year Old with Vaginal Discharge

Thanks so much for you help!!

God Bless,
-Simone

Dear Simone: A vaginal discharge that occurs as a result of injury would usually be associated with pain, or at least an injury that can be remembered. I cannot imagine that we are talking about internal bleeding in the absence of significant injury and abdominal pain. If you examine your daughter's perineum, the area between the anus and vagina, and you check the external appearance of your daughter's vagina, and in those two areas you see no raw or open tissue, I would consider vaginitis, an inflammation of the vagina, more likely. Usually a discolored discharge can be seen with a foreign body in the vagina such as a piece of toilet paper which has gotten stuck. The best treatment would be sitz baths - soaking in a few inches of warm water without soap 3 or 4 times a day. The friction and irritation your daughter complains about from the leotard may be the cause or a contributing factor. You might try letting her apply some Vaseline or A&D ointment as a lubricant and wearing a light pad to decrease the irritation from the leotard. If a discolored discharge persists in spite of these measures, your daughter should see her doctor.

Sincerely,
Dr. Warren

Feel free to call me collect at (xxx) xxx-xxxx or email me.

Respectfully,
-[name withheld]

March 30, 19XX
THE HONORABLE XXXXX
U.S. SENATE

Dear Senator Xxxxx:

I am writing you to request your assistance concerning the Xxxxxx Air Force Base Regional Medical Center's actions concerning my 6 year old daughter Kxxxxx.

A cautious and relatively new military Pediatrician (attachment #1) has raised a concern of sexual abuse of my 6 year old daughter Kxxxxx.

Kxxxxx was being seen by Dr. XXXXXXXX2 her Primary Care Manager for a persistent urinary tract infection since July 1997. Dr. XXXXXXXX2 was sent on duty out of the pediatric clinic. Kxxxxx's original medical record came up missing at that time. Dr. XXXXXXXX3 entered the picture he ordered another sample of urine be taken from her kidneys via a catheter. Kxxxxx was held down by four persons and the catheter was inserted while Kxxxxx thrashed around, it took a couple of tries to place it properly. Dr. XXXXXX3 ordered treatment with another course of medicine.

My wife returned Kxxxxx to the clinic for a follow-up appointment after Dr. XXXXXXXX3 treatment. Kxxxxx was seen by Dr. XXXXX4 and she recommended a follow up with her regular Primary Care manager. Dr. XXXXXXXX enters the picture upon reading Kxxxxx's chart in a records staging area consisting of three consultation sheets not the full medical record. She requests records of all previous laboratory tests. Dr. XXXXXXXX requests another follow up visit. Questions about possible sexual abuse were put to both my wife Helen and Kxxxxx. Helen said that abuse is very unlikely. Kxxxxx said nobody has touched her privates or hurt her except for a "wedgie" by her brother. Dr. XXXXXXXX wants to do a colposcope vaginal exam of Kxxxxx who refuses to submit as she is scared because of the previous two forced catheterizations that inflicted pain on her. At this time Dr. XXXXXXXX implies because of the long treatment period etc. she suspects sexual abuse is a possible cause. Dr. XXXXXXXX insisted Kxxxxx be sedated to perform the exam. I begged Dr. XXXXXXXX to give Kxxxxx one more try to submit without sedation. Kxxxxx refused again and we submitted her to the sedation to allow the exam to ensure her proper care and treatment.

On 5 March 19XX upon the end of the exam where lab cultures and slides of Kxxxxx's hymen were taken. Dr. XXXXXXXX told my wife and I she believes "the hymen is abnormal and I am not the expert on this, when the experts review this it may be considered within the range of normal". She might send them to an expert on Child Abuse in Washington DC whom used to work at Xxxxxx AFB. I requested copies of the photos so that at my own expense I could get them looked at by an expert in the field so I would not have to wait for the Air Force Expert. I was told I could not have copies of them and had to wait for the Air Force Expert. She also stated that the photos would not be back from printing till 9 March XX. I asked her if this damage to the hymen could've have been done with the catheter placements she replies "I don't think so as the two areas are 1 centimeter apart in placement and the technicians should know the difference between a vagina and the urethra opening". Dr. XXXXXXXX was not present during the two previous forced catheterizations and knows nothing about the amount of struggling Kxxxxx did. When the placement was done, Kxxxxx was kicking, crying, and trying to get loose like her life depended on it. Four adults were required to control her and place it. She also states she is reporting this as Highly Suspicious of Sexual Abuse to the Family Advocacy Program, Office of Special Investigations, my Squadron First Sergeant/Commander and State Child Protective Services. Dr. XXXXXXXX states if the cultures are negative for sexually transmitted organisms they are inconclusive as it is hard to culture things from a prepubescent girl. Family Advocacy states that Kxxxxx's statement of not being abused doesn't mean anything because "young children block out memories of unpleasant things". This seems strange as Kxxxxx can tell you how many people held her down when they hurt her with the catheter and a previous incident when they took blood for a lab test. Family Advocacy then states after they get to question her she may remember something. On 9 March xx Dr. XXXXXXXX called my home to tell us the slides came out okay, Kxxxxx needed treatment for Escherichia Coli, and some slides were sent to Office of Special Investigations who will decide if they need to send them out for further evaluation. When asked about copies of the slides she again said it wasn't up to her to release them but we could have copies of her record sheets if we came to the clinic.

On 13 March 19xx the state of [name of US state withheld] forcibly seized Kxxxxx from her school. She was kept in a shelter and separated from her family, school, friends and subjected to numerous interviews by the State of [name of US state withheld]. On 17 March 19xx the Family Court Judge would not release her from the shelter based upon statements via a phone call to Dr. XXXXXXXX. The judge stated upon reentering the court from chambers that the doctor stated "70 to 80 % sure the abnormalities were caused by sexual abuse and could be nothing else in the doctors opinion". The judge also said that per Doctor XXXXXXXX the abnormality was such that when it had happened to Kxxxxx she would have had to of cried out in pain. In my opinion Dr. XXXXXXXX did not qualify her opinion like she did to my wife and myself with the part about " when the experts review this it may be considered within the range of normal". Doctor XXXXXXXX's now one sided opinion left the judge no option but to hold Kxxxxx in the courts custody. The judge ordered us to not speak to Kxxxxx about why she was in the shelter or the doctors opinion but we were allowed to see her during supervised visits at the shelter. Further the judge ordered Kxxxxx to be interviewed (attachment # 2) in Jackson [name of US state withheld] at the Child Advocacy Center on 20 March 19xx and be held for two weeks and interviewed a second time. On the evening of 23 March 19xx we were notified by our lawyer that Kxxxxx has been interviewed seven times (between on and off base) and consistently denied anybody touching her. On 25 March 19xx Kxxxxx was finally released ahead of the judges schedule to us.

My reading (attachment # 3) from the Xxxxxx Medical Reference Library indicates everything noted in Kxxxxx's medical record extract(attachment # 4) could be a normal occurring defect in the population. just like Dr. XXXXXXXX told my wife and I on 5 March 19xx. The material shows disagreement by the experts in the field but the one thing they agree on is these abnormalities must have collaborating data to indicate sexual abuse. The collaborating data would be the child says they were abused, clear evidence of trauma or sexually transmitted diseases are found. None of these indicators are present with Kxxxxx. The only organism found was Escherichia Coli which some young girls get from wiping from back to front when using the bathroom.

Why after Dr. XXXXXXXX doubted her own opinion did she not have a moral and ethical duty to tell of the same doubts to the state social services and the judge after she made the child abuse report? I believe the state would not have seized Kxxxxx if the doctor had told them of the possibility of the findings of abnormal being within the range of normal. Why weren't the slides express mailed out to the Air Force Expert on 9 March xx. What about the Principles of Medical Ethics (attachment # 5) to deal honestly with patients and consult and use the talent of other health professionals when indicated? Clearly this was indicated by the doctors own statements on 5 March 19xx. Why can't I have copies of the slides to get my independent review? Why is nobody concerned about their actions effect on Kxxxxx and only with complying with the child abuse laws? There seems to have been no urgency on the Air Force's part to prevent the seizure and abusive emotional trauma of Kxxxxx but only to minimally comply with the child abuse laws.

Since Kxxxxx's return from the shelter she has expressed a fear of going to school. Kxxxxx previously looked forward to going to school on Mondays and said she was bored on the weekends. When questioned about her fear of going to school she replied " Daddy I'm scared the strange black ladies will come get me again". Kxxxxx has had numerous accidents defecating in her pants since returning from the states custody. Previous to this incident it had not occurred in years. Kxxxxx now is afraid to sleep alone in her room and her mother has to stay with her till she falls asleep. Kxxxxx never had this problem before. I attribute these behavioral changes to disruption of her normal lifestyle and the shear terror of losing her family contacts. The Air Force Family Advocacy social worker has been asked for help with on how to deal with these behavior changes. During our talk about Kxxxxx he stated that just because Kxxxxx has stated seven times that nobody touched her that only means that Kxxxxx truly believes she told the truth. He then went on to say that she might have been sexually abused while asleep and truthfully doesn't remember it. This seems strange because Doctor XXXXXXXX said previously that in her opinion Kxxxxx would have had to screamed out in pain when it happened. So this would cause her to scream in pain and not wake her from sleep? It seems the system professionals involved do not want to even consider that nothing has happened to Kxxxxx and that they have needlessly caused tremendous harm and abuse to her for no good reason..

In conclusion, I urge you to investigate this matter further. The Air Force's actions met minimum statutory requirements but exposed my daughter to extreme emotional abuse and disruption of her life resulting in permanent emotional changes. How can one doctor with only about 2 or 3 years experience since General Pediatrics certification who expressed her own doubts about the interpretation of an exam put Kxxxxx through all this without a timely peer review. Kxxxxx was steamrollered by the system after the initial report was made. The system seems broken and nobody at Xxxxxx AFB wants to improve it.

Sincerely,
[name withheld]

Attachments:

# 1 American Board of Pediatrics Verification of Certification,
# 2 Child Advocacy Center Interview Initial report,
# 3 Extracts from "Child Abuse a Medical Reference",
# 4 Medical record extracts,
#5 American Medical Association Principles of Medical Ethics

Dear Sir: I'm absolutely flabbergasted by your story, but I'm not sure I have any answers for you. From the point of view of clearing your name, CPS has closed the investigation and your daughter is back with you, so your name is cleared. I do not believe there is any way you can make the records of what happened disappear. As regards your obtaining copies of medical records, including copies of the findings of the expert, you should check your state laws regarding release of records. In New York State, it is professional misconduct not to provide a copy of a medical record to which the patient is legally entitled. I do not know how the allegation of abuse or the fact that you are in the military may factor into this, but I would suggest you contact a lawyer since what's really at issue now are yours and your daughter's rights.

I can't believe that nobody involved, especially the people at CPS who are charged with protecting the children, is willing to look at the events in retrospect with an eye toward seeing what went wrong. The harm done to your daughter cannot simply be justified on the grounds that it was necessary to follow procedures to protect her. Any agency or institution should be willing to review procedures with an eye toward improving them, and a case such as this should make the agency review its procedures, even though it is too late for your daughter.

Since I didn't see what the doctor saw which made him suspect abuse, I cannot comment on the validity of his findings, but I do have at least a few concerns about the mishandling of this case.

1. It is not clear to me what made the doctor consider sexual abuse in the first place. Neither recurrent urinary tract infections nor a torn hymen would constitute sufficient reason to consider sexual abuse. Unless there was evidence of injury or penetration besides the appearance of the hymen, the doctor is ignorant of the fact that the appearance of the hymenal ring which can tear from normal activity like bicycle riding, cannot be used as the sole indicator of abuse.
2. The bladder catheterization was not an emergency procedure. Since it should be possible to get a reliably clean specimen in a 6 year old, I'm not even sure it was an essential procedure. But it shouldn't have been necessary for it to be so traumatic. Your daughter could have returned sedated for the procedure or been referred to a pediatric urologist if there was a great deal of concern about what was happening in her urinary tract.
3. Once the allegation was raised, since your daughter had regular care before the allegation, her primary pediatrician should have been contacted no matter where he was. His opinion about the question of abuse should have been considered essential since he had been caring for her up to that point.
4. If the pediatrician who first became concerned about the issue of abuse was inexperienced, she should have consulted another pediatrician prior to subjecting your daughter to an invasive procedure. If she felt that the law required her to act on her mere suspicion, she could have opened a case file with CPS without doing culposcopy. What's more, as long as you daughter was in your custody, you would have been within your rights to refuse the exam. You should have been given a more complete explanation of the risks and benefits of the exam (psychological trauma being a risk). If the decision to allow the exam was made under the threat of reporting sexual abuse and the exam provided no clinical benefit other than to look at that possibility, you were coerced into allowing the procedure.
5. I can't help but wondering if the State of [name of US state withheld], or any of our other great states haven't figured out that strangers showing up and taking a child is no different to the child than being kidnapped. I understand that you were suspects at the time, but if CPS had investigated you and your family, unless there was a risk you would abduct your child and flee, they should have been able to arrange something with relatives or at least allow you to help ease her way from the school.

As regards an additional expert, you could have your daughter seen by another pediatrician, but 10,000 second opinions in your favor won't change what's in her chart. I would suggest at this point that your daughter's interests are best served by getting her counseling. An additional expert opinion would only be useful if there is further legal action, in which case, your lawyer could best direct you toward an expert.

Sincerely,
Dr. Warren

His letter is dated 21 March XX. the doctor who made the allegations refused to give it to us and has been holding it since then. I had to force it's release under threat of penalty under the Privacy act of 1974. My court hearing to release my daughter was on 25 March XX. This non-supportive review of her opinion was never sent to the state or the judge to review. The negative lab reports for STDs were also never sent to the state or the judge.

My daughters assigned Primary Care Manager was never shown this expert opinion as of a visit to her on 30 April XX. She stated all she knew of the exam was what the other doctor verbally told her about the slides. As far as she knew the expert opinion was given via telephone only to the other doctor.

The accusing doctor only told the Air force Family Maltreatment Management Board that the Expert was not as suspicious as her. This was stated in April XX and she never showed or introduced the experts letter to the board.

The Air Force Congressional Liaison Officer contacted my Senators staff on this Wed. and explained that they had missed the 30 day suspense deadline due to a review of the answer by the legal channels. Then they stated that they didn't understand what I was concerned about because I had my daughter back and no charges were filed against me. They wanted a list of my concerns and what I wanted done about it. This is an insult to me as the first letter covered my concerns and the second below letter addresses my other concerns over the perceived attempt to hide the Experts opinion from myself and the state.

What do you think of these latest developments and the withholding of the experts opinion after it came back in March? Is this the kind of ethics actions that a professional peer group might investigate? Whom would that be? The State Board of her Medical license or does the AMA conduct ethics violations probes?

By the way I have taken my daughter to a civilian Urologist who said he thinks she has been fine since last September. He stated the VCUG looks normal as well as her bladder ultra sound. He attributes the small number of White Blood Cells since the initial treatment as being due to my wife catching the urine that first came out instead of mid stream after the urethra was flushed. He said they should have asked about the collection technique when it kept showing up numerous times after treatment with medicine that the lab tests said would kill the E-Coli. It's a great relief to know my daughter has no condition that could impact her quality of life by damaging her kidneys. He can not understand how they got there(the abuse allegations) with what was in her record.

I am very appreciative of your opinions concerning the ethical issues involved and will let you know what develops. As you know our great government moves slowly at times.

Respectfully,
-[name withheld]

THE HONORABLE XXXXX
U.S. SENATE
ATTN: XXXXX

Dear Xxxxx:

The U.S. Air Force Expert’s opinion letter is enclosed. The letter is dated 21 March 19XX on this date Kxxxxx was still in the State ran shelter. The Youth Court Judge was not able to read this opinion before the final hearing. Carolyn O’Banner at Jackson County DHS told me on 4 May XX that as the investigator on Kxxxxx’s case she had not been given this opinion letter by the Air Force to date. Doctor Rxxxxx who was assigned as Kxxxxx’s Military Primary Care Manager(PCM) and Pediatrician had not been furnished this letter or shown it as of a visit to her clinic on 30 April XX. Doctor Rxxxxx was not consulted before the report was made by Dr. Xxxxx to the state. My wife and I were never told of the experts opinion content when it was received back in March. We had to gain access to the exam photos and opinion via the Freedom of Information Act and the Privacy Act office on Xxxxxx AFB. We have been told numerous times we could not have the photos unless we got a court order. A request by Kxxxxx’s new civilian doctor on his medical record transfer request form was ignored and referred to us not him with another verbal "you can’t have the photos without a court order" . I have included the American Academy of Pediatrics Policy Statement, Guidelines for the Evaluation of Sexual Abuse of Children(RE9202) and the Table 2. referenced in it.

Once again all the documents and information points to the lack of corroborative history and medical results making the report to DHS possibly premature at the least or questionable at best.

Feel free to contact me at home: xxx-xxx-xxxx work: xxx-xxx-xxxx.

My home of record and my absentee voting address is ~~~~~~~

Sincerely,
[name withheld]

Dear Sir: It sounds like the doctor who reported the sexual abuse was on a crusade. She was so convinced of the righteousness of her actions, she didn't want to risk providing any information which didn't support her opinion. People in any profession who chose to ignore facts which contradict their opinions are dangerous.

The doctor's actions were not only unethical, but also they resulted in psychological harm to your daughter. It amazes me what tunnel vision every person involved has. Each only sees his narrow view of the incident and refuses to look at the big picture for fear he'd have to take responsibility for changing a system out of control.

To be honest, I have never had any involvement in the AMA and have no idea if they would have an interest in your situation. I doubt they would have any means to discipline the doctor. You should contact your state licensing board and your state peer review organization to find out how to proceed in lodging a complaint.

Sincerely,
Dr. Warren

The fact that she did not give us (the parents) the USAF Experts opinion was an innocent oversight they said that telling us was not important. The issue of not giving the non-supportive data to CPS was because they were worried about our privacy. What a comment when they made the report they did not worry about our privacy. They also said the Court and CPS didn't want the information most likely. The fact that not furnishing this information appears to violate the Rules under USC Title 5 The Privacy act is no big deal to them.

What upsets me the most is they stated they would do it the same way in the future. The Doctor stated she makes about three of these reports a month this adds up to over 100 reports since I've been stationed here at this base. In the years I've been here there has only been one court martial in this subject area and it was reported by a neighbor. I would guess their confirmed number out of over 100 reports would be about zero or one each.

There must be some way to encourage this out of control system to change. The reporting procedures are sound but the first link in the chain the Doctor seems to be on a crusade and the military system only wants to protect its own officers. Once a medical opinion is made the system has to act. I can't believe they will not see the damage they are causing to the children they claim to act on behalf of. Is there anyway to force a review by peers in the civilian medical community?

What do you think? Any suggestions?

Respectfully,
-[name withheld]

Dear Sir: A nonspecific finding is one which is expected with a certain diagnosis, but can be found in other conditions so that it is not diagnostic. For example, a runny nose is a nonspecific finding with a cold. Noses can run because of allergies as well as colds. A specific finding is one which is considered diagnostic by its nature because it is only found under certain circumstances. The rash of chicken pox is a specific finding because it is only seen with chicken pox. This assumes, however, that the physician examining the rash has enough experience to distinguish it from similar rashes.

Bruising around the genitals would be a specific finding of sexual abuse, but even that may depend on the history since I have had patients with genital injuries which occurred as a result of unusual circumstances. So would scarring of the genitals or semen in the vagina of a child. Whether an abnormality of the hymen could be considered a specific finding of abuse may be subject to interpretation since it depends on what the doctor means by abnormality. The hymen is a thin membrane which could be rudimentary in some girls and could tear from activities like bicycle riding. If the doctor concludes that the hymen is abnormal if it is not intact and considers that a specific finding for abuse, I would disagree. On the other hand, an intact hymen does not rule out abuse. It only rules out penetration.

Some nonspecific findings are more strongly suggestive of a particular diagnosis than others. Taken with other clinical findings, medical history, and test results, nonspecific findings can lead to a diagnosis. That's what a good part of the diagnostic process is about. The fact that so many findings are nonspecific explains why doctors don't always know a diagnosis immediately after an examination and why they so often say "it could be this" or "it could be that."

I don't know the procedures for peer review or filing complaints as they vary from state to state and country to country. You might contact a local medical society or the licensing board to see if they can elucidate the procedure.

Sincerely,
Dr. Warren

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