Before St. Louis Children's Hospital had a child protection program, there was Nancy Duncan, a staff nurse in the emergency room whose mother had taught her at an early age to say "penis" and "vagina" without blushing.

"When a case of child maltreatment and, often, sexual abuse came in, everybody else went to the bathroom and I'd be standing there," recalls Duncan, who started at St. Louis Children's in 1979. "I realized there was a lot we needed to do to serve these kids well."

Now well established, the St. Louis Children's Child Protection Program had its beginnings in a proposal Duncan wrote in 1983 asking the hospital to allow her to specialize in child maltreatment and sexual abuse cases. "What I was hoping to do was to be able to examine them and make sure they were getting follow-up lab tests and the care they needed for sexually transmitted diseases," she says. "And then be able to get training to interview the children."

Adrienne D. Atzemis, M.D., an assistant professor of pediatrics who has worked in the Child Protection Program for the past year and a half, says Duncan deserves credit for building the program from the ground up. "For many years, she was the sole practitioner," Atzemis says. "It has resulted in many, many children receiving evaluations. It's one of those programs you don't know exists until you need it. And when you need it, it's there."

By 1983, Duncan had trained to become a nurse practitioner so she could better deal with abuse cases. The additional education "really helped expand my role," she recalls. "I learned how to do a physical examination and how to document. I learned more about lab tests and child development and how to help kids talk about and deal with things."

In 1986, the hospital allowed Duncan to start the program with the help of two social workers who were assigned to child abuse. At first, Duncan and her co-workers recruited doctors from the community to volunteer one afternoon a week. By 1992, the hospital hired a pediatrician, Robert T. Paschall, M.D., to work part time in the ED and part time with child maltreatment. Paschall, now medical director of the hospital's Child Protection Services/Sexual Abuse Management Clinic, helped develop a fellowship training program and made sure that every first-year resident spends time in the clinic.

"Every resident does a two-week training with us," Duncan says. "At lots of places, residents get out of medical school and they don't know how to do a normal exam on a little girl."

Today, the Child Protection Program has grown to include two attending physicians who were among the first to be certified by the American Board of Pediatrics in child maltreatment and child abuse. The staff also includes a fellow studying to be a certified child abuse pediatrician and about six social workers who work in child abuse. Besides her work at the hospital, Duncan testifies as an expert witness in court in child maltreatment cases, the first nurse practitioner in Missouri to do so. She also advocates on the state level for expanding child maltreatment services to undeserved, often rural, areas.

Atzemis says Duncan is particularly gifted at listening well, while drawing people out and dealing with families in a nonjudgmental way. "When you're working with families of many different backgrounds, sometimes it's easy to judge," Atzemis says. "She's able to relate to people of different backgrounds and has the ability to really reach out and be compassionate."

Duncan, whose pediatric clients have ranged in age from a 2-week-old baby with gonorrhea to 20-year-olds with intellectual disabilities, says, for the most part, families of suspected child abuse victims are willing to work with her. "I think the people they meet can be pretty judgmental," she says. "The parents feel incredibly guilty in the first place [that their child may have been sexually abused]. So, if you can reach them on a level where you're on their side and you're here to help, they respond well. You may get a mother in here who's been vilified by everybody she has looked at for the last week. We try to have a conversation in which nobody vilifies her and people are trying to help."