Management of Childhood Sexual Abuse

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Management of Childhood Sexual Abuse

• NEIL McKERROW
• Department of Paediatrics
• Pmb Metropolitan Hospitals Complex

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Understanding medical qualifications

• Who to believe?
• (Is he a quack or is he for real!)

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Medical qualifications !!!

• Helpful in establishing the expertise of a
  medical witness.
• Expert on the basis of
• Specialised knowledge (profession)
• Expertise (knowledge and experience).

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Qualifications

• Other (non medical)
• BA / BSc
• Basic (undergraduate)
• MBChB / MBBS etc
• Advanced (postgraduate)
• Diplomas
• DCH / Dip For Med
• Specialist
• University MMed (..)
• College Fellowship (FCP)

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Registration

• HPCSA
• Student
• Intern
• CSO
• Medical practitioner
• Independent practice
• Public service
• Specialist
• Knowledge qualification
• Experience registrar training time

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Medical hierarchy 1
Level Experience Comment
Intern Nil Supervision
CSO Nil Supervision
MO Nil 1 year
SMO 2 years
PMO 4 years Foreign specialist
CMO 6 years Foreign specialist
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Medical hierarchy 2
Level Experience Comment
Registrar Variable Training
Specialist Nil 4 years in training
Senior Sp 2 years
Principal Sp 2 (6) years
Chief Sp 6 (10) years
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Expertise

• Knowledge
• Qualification
• Additional training
• Experience
• Years as doctor
• Years in specialist field
• Intensity of practice ie case load
• Other roles
• Research
• Teaching
• Programme development

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Nomusa

• 12 year-old female
• ? Emerging teenager
• Withdrawn uncommunicative
• Gaining weight
• Attended hospital
• Pregnant
• Abused over 5 week period
• Normal genital examination

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Lessons - 1

• Disclosure is relative suspicion essential
• Normal examination does NOT mean no sex
• Pregnancy can occur before menarche

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Sarah

• 3 year old female
• Abnormal social environment
• Abnormal behaviour
• Suspicious examination
• Angry parents
• Allegations of abuse
• Consent for examination
• Admission to hospital

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Lessons - 2

• Responsibility is to the child
• Systems exist to facilitate this
• SAP 308
• Form 4
• Consultation helps
• The system is flawed

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Concepts

• Understand concepts
• Physical abuse
• Sexual abuse
• Dynamics of disclosure
• Spontaneous
• Prompted

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Definition

• Involvement of a child in sexual activity
• Without consent
• Without understanding
• Contrary to norms of society
• Sexual activity involving a child in which there
  is a power imbalance

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Finkelhors perpetrator

• 4 stages to abuse
• Desire
• Overcome internal inhibiting factors
• Overcome external inhibiting factors
• Overcome the child
• Seduction
• Bribery
• Threats
• Force

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Framework for care of abused children

• Suspect
• Investigate
• Validate
• Treat
• Ensure safety
• Family reconstruction

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Suspect

• Disclosure
• Symptoms
• Findings

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Investigation

• Welfare
• Circumstances risk of abuse
• SAPS
• Crime
• Health
• Explore differential diagnosis/presenting
  complaint
• Support SAPS investigation

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Protocol for examination

• Time
• Privacy
• Consent
• Parent /or SAP 308
• Child
• Participation
• Support
• System

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What to say

• Set the child at ease
• Confirm the nature of his/her problem
• Explain your role
• Explain the procedure
• Chaperone
• Examination
• Specimen collection

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What to do

• History
• Examination
• Investigations
• Forensic
• Medical
• Reports

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What to look at

• The whole child
• Stage of puberty
• Genitalia
• Anus

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What to look for

• General trauma
• Genital/anal
• Trauma
• Penetration
• Complications
• Infections
• STI
• Pregnancy
• PTSD

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What does it mean

• Clinical findings
• Significance considers
• Story
• Clinical findings
• Investigations

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Collection of forensic evidence

• Within 72 hour
• With knowledge consent
• Maintain integrity of specimen
• Maintain chain of evidence

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Completion of J88
Crucial
Your story
Childs story, including date source
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Treatment

• Mental
• Debriefing
• Counseling
• Physical
• Treat problems
• Prophylaxis

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Treatment

• Injuries
• Infections
• STIs
• Pregnancy

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Prophylaxis - infections

• Within 72 hours
• Tetanus
• ATT
• STIs
• Ceftriaxone
• Flagyl
• Erythromycin
• HIV
• AZT 3TC

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Prophylaxis - pregnancy

• Tanner stage 3
• Pregnancy test
• Ovral 28
• Maxalon
• Follow-up

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Ensure wellbeing

• Known perpetrator
• Removal
• Unknown perpetrator
• Empowerment

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Hospitals as places of safety

• Admit for medical reasons only
• Last resort as a place of safety
• More likely in rural settings
• Requires a Form 4

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EXAMINING CHILDREN

• The doctors despair.

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PREPARATION

• Set the child at ease
• Confirm the nature of his/her problem
• Explain your role
• Explain the procedure
• Chaperone
• Examination
• Drapes - children
• adolescents
• Specimen collection

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PROCEDURE

• General examination
• Tanner staging
• Genital examination

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NORMAL GENITAL ANATOMY DEVELOPMENT

• Chaos confusion!

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FEMALE GENITAL DEVELOPMENT

• 3 phases
• Infancy
• Childhood
• Adolescence
• 3 features
• Oestrogen levels
• Size
• Mucosal surface

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FEATURES OF SEXUAL ABUSE

• The prosecutors despair.

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Determining factors

• Age
• Oestrogen profile.
• Vaginal environment.
• Nature of Abuse
• Rape
• Seduction.
• Acute vs chronic.
• Time lapse
• Short.
• Long.

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Features.

• Evidence of genital trauma.
• External genitalia.
• Internal genitalia.
• Structural hymenal changes
• Trauma
• Tears Clefts / Notches.
• Dilatation.
• T/V diameter posterior rim.
• Foreign matter
• Semen.
• Sequelae
• STIs.
• Pregnancy.

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Sequelae

• Phsyical
• Acute trauma.
• Evidence of penetration 30.
• STI similar prevalence to broader community
• Syphilis 1,8.
• Pregnancy 1 1,5 of post pubertal girls.

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Vaginal penetration

• Acute genital trauma
• Short lived
• TEARS
• Hymenal changes
• Permanent
• Stretching
• Structural changes

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J88 genital anatomy

• How to mess with your colleagues mind.

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Sections A B
Crucial
Crucial
Story, including date source.
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Section C
Ht wt help support age
Details of extra-genital trauma
Critical to comment on state during examination
Conclusion re general wellbeing Worth adding who
was present during exam
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Section D
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Section E
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Section F
Indicate what, if any, specimens sent to local
laboratory Interpretation of clinical findings
with reasons not legal finding
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Section G
Interpretation of above findings with reasons
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Anal penetration

• Muco-cutaneous changes
• TEARS
• Dilatation
• Speed extent
• Venous engorgement
• Speed

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Section H
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Drawings
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INTERPRETATION OF CLINICAL FEATURES

• What does it all mean?

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CLASSIFICATION OF ANOGENITAL FINDINGS

• Class 1 - Normal
• Class 2 - Nonspecific
• Class 3 - Suspicious
• Class 4 Suggestive
• Class 5 Clear evidence of penetrating injury
• Pediatrics 1994 94 311

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NORMAL

• Periurethral bands
• Intravaginal ridges or columns
• Erythema in sulcus
• Hymenal tags, mounds or bumps
• Elongated hymenal orifice in obese child
• Ample posterior hymenal rim (1 2 mm)
• Oestrogenic changes
• Diastasis ani / smooth area in perianal midline
• Anal tag / thickened fold in perianal midline

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NONSPECIFIC

• Erythema of vestibule
• Increased vascularity of vestibule / hymen
• Labial adhesions
• Rolled hymenal edges
• Narrow hymenal edge, at least 1 mm
• Vaginal discharge
• Anal fissure
• Flattened / thickened anal folds
• Anal dilatation with visible stool
• Venous congestion of perianal tissue (delayed)

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SUSPICIOUS

• Enlarged hymenal orifice
• Posterior hymenal rim lt 1 mm
• Acute abrasion or laceration of labia or
  vestibule
• Condylomata accuminata
• Immediate anal dilatation with no visible stool
• Immediate perianal venous congestion
• Distorted, irregular anal folds

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SUGGESTIVE

• 2 or more suspicious anal or genital findings
• Scar or laceration of posterior fourchette with
  sparing of hymen
• Scar in perianal area

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CLEAR EVIDENCE OF PENETRATING INJURY

• Hymenal notch between 3 and 9 oclock
• Hymenal transection or laceration
• Laceration of posterior fourchette extending to
  involve hymen
• Scar of posterior fourchette with loss of hymenal
  tissue between 5 and 7 oclock
• Perianal laceration extending deep to external
  anal sphincter

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LIKELIHOOD OF SEXUAL ABUSE

• Class 1 No evidence of abuse
• Class 2 Possible abuse
• Class 3 Probable abuse
• Class 4 Definite evidence of abuse
• Pediatrics 1994 94 311

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NO EVIDENCE OF ABUSE

• Normal examination, no history, no behavioural
  changes, no witness
• Nonspecific findings with another aetiology and
  no history or behavioural change
• Child considered at risk for sexual abuse, but
  gives no history and has nonspecific behavioural
  changes

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POSSIBLE ABUSE

• Class 1, 2 or 3 findings in combination with
  significant behavioural changes but child unable
  to give history of abuse
• Condylomata or genital herpes in absence of a
  history of abuse and otherwise normal examination
• Child has made a statement but this not
  consistent or detailed

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PROBABLE ABUSE

• Child gives clear, consistent and detailed story
• Class 4 or 5 findings with no convincing history
  of accidental penetrating injury
• Culture proven infection with Chlamydia
  trachomatis in a prepubertal child over 2 years
  of age

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DEFINITE EVIDENCE OF SEXUAL ABUSE

• Finding sperm of seminal fluid in or on a childs
  body
• Witnessed episode of sexual molestation
• Nonaccidental, blunt penetrating injury to the
  vaginal or anal orifice
• Confirmed infection with Neisseria gonorrhoea or
  Syphilis

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MEAN HYMENAL MEASUREMENTSPediatrics 1992 89
393
lt 12 m 13 24 m 25 48 m 49 81 m
Horizontal 2,5 mm 2,9 mm 2,9 mm 3,6 mm
Vertical 3,4 mm 2,8 mm 3,6 mm 3,9 mm
Inferior rim 2,8 mm 2,7 mm 2,7 mm 2,7 mm
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MEAN HYMENAL MEASUREMENTSPediatrics 1990 86
436
2 4 years 5 8 years gt 8 years
Separation Vertical 5,5 mm 5,6 mm 8,4 mm
Horizontal 3,9 mm 4,2 mm 5,7 mm
Traction Vertical 5,5 mm 6,1 mm 8,3 mm
Horizontal 5,2 mm 5,6 mm 6,9 mm
Knee-chest Vertical 6,3 mm 7,0 mm 8,7 mm
Horizontal 4,6 mm 5,6 mm 7,3 mm