Knee-Chest Position Triggers Further Discussion

To the editor:

I am responding to Dr. Joyce Adams' article January/February forensic nurse regarding the knee-chest position article that I co-authored with Dr. Betsy Gibbs. Like Dr. Adams, Dr. Gibbs has been evaluating child abuse victims since . She has been practicing exclusively as a forensic pediatrician and has performed such evaluations for at least 5,000 children. I have personally performed almost as many of these examinations as Dr. Adams. Regardless of our credentials, I must take you to the place where this article was born.

I was in a conference peer review session as I watched in horror a videotape of a nurse practitioner with a prepubescent child's bottom in the air for more than 5 minutes, as she poured water on the child's hymen with a pipette. There were no signs of trauma from what I was able to distinguish, and it seemed almost as if she were searching for these signs. Later, when I tried to find guidelines as to the use of the knee-chest position, I realized that there were none. I also found, as mentioned in my article, that there was no data to warrant the use of this position, and in fact, there was much contradiction regarding the findings that were obtained from its use, even among the same researchers. I do not dispute Dr. Adams' statements about the percentage of children with histories of abuse who, in fact, have normal exams, as this is common knowledge among child maltreatment practitioners. However, in any other specialty area of medicine, such a procedure would not be used without guidelines and relevant data regarding its use and findings. Dr.Adams suggests that without this methodology, it is likely that examiners may mistakenly call findings positive which are actually normal. In my experience, it is usually the other way around, whereas a provider, based on history, is not satisfied with the normal findings they have and then "flip" the child into the knee chest position in order to seek more information. Because there are no guidelines or data available for the use of this method, such findings would be considered "subjective" as opposed to "objective" in the scientific realm.

I have spoken with some of the researchers regarding guidelines, and even among them, there is disagreement regarding the ages that this method should be used. One researcher stated to me in an e-mail that "all adolescent females" should be put into this position, whereas Dr. Adams states that this is not necessary. From my experience, this is a humiliating examination in its own right for most adolescent females, much less to be examined face down with the bottom in the air. I believe that until there is relevant data as to the findings, and guidelines as to its use, this exam method should be used cautiously, if at all. I do not believe that Dr. Adams' article gave any significant data regarding this method. I additionally believe that using photo documentation and labial manipulation, I would have been able to assess the child whose photo was used without using the knee-chest position. I have never had to use this method to obtain the necessary information, nor would I ever call an unsure finding positive, as I was educated under the principle that "if your brother, husband, son, were the alleged offender, would you be sure enough to send him to jail?"

I don't believe that possibly abused children must be further traumatized in the name of justice. Additionally, when a child is in an exam room with a medical provider, they are likely to do just about anything they are asked, especially if they have been abused in the past. This doesn't mean that they feel good about it. I believe that medical examinations of children can be a healing and empowering experience, where they can be assured that their bodies are okay, and some modeling regarding boundaries and respect can occur. However, I also understand that I am coming much more from a nursing, as opposed to a medical perspective. Comparatively speaking, CT scans are helpful for assessing the degree of head injuries, but you aren't going to order one every time a child gets a "goose egg." In fact, the AAP has guidelines as to the use of CTs for assessing head injuries in children. Isn't it time that medical providers who specialize in child maltreatment begin using the same evidence-based principles for evaluating children as the rest of medicine is expected to? Finally, I think that the original article was very clear as to not using cotton swabs on pre-pubescent females.

Gretchen Overstolz, RN, MSN

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