Management of Childhood Sexual

Abuse

NEIL McKERROWDepartment of Paediatrics

Pmb Metropolitan Hospitals Complex

Understanding medical qualifications

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

Medical qualifications !!!

• Helpful in establishing the expertise of a medical witness.

• Expert on the basis of: • Specialised knowledge (profession)• Expertise (knowledge and experience).

Qualifications• Other (non medical)

• BA / BSc• Basic (undergraduate):

• MBChB / MBBS etc• Advanced (postgraduate):

• Diplomas• DCH / Dip For Med

• Specialist• University MMed (…..)• College Fellowship (FCP)

Registration• HPCSA

• Student• Intern• CSO• Medical practitioner

• Independent practice• Public service

• Specialist• Knowledge – qualification• Experience – registrar training time

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

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

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

Nomusa 12 year-old female ? Emerging teenager

Withdrawn & uncommunicative Gaining weight

Attended hospital Pregnant Abused over 5 week period Normal genital examination

Lessons - 1

Disclosure is relative & suspicion essential

Normal examination does NOT mean no sex

Pregnancy can occur before menarche

Sarah 3 year old female Abnormal social environment Abnormal behaviour Suspicious examination Angry parents

Allegations of abuse Consent for examination Admission to hospital

Lessons - 2 Responsibility is to the child Systems exist to facilitate this

SAP 308 Form 4

Consultation helps The system is flawed

Concepts

Understand concepts: Physical abuse Sexual abuse

Dynamics of disclosure: Spontaneous Prompted

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

Finkelhor’s perpetrator 4 stages to abuse:

Desire Overcome internal inhibiting factors Overcome external inhibiting factors Overcome the child

• Seduction• Bribery• Threats• Force

Framework for care of abused children

Suspect Investigate Validate Treat Ensure safety Family reconstruction

Suspect

Disclosure Symptoms Findings

Investigation Welfare:

Circumstances & risk of abuse

SAPS: Crime

Health: Explore differential diagnosis/presenting

complaint Support SAPS investigation

Protocol for examination

• Time• Privacy• Consent:

• Parent &/or SAP 308• Child

• Participation• Support• System

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

What to do

History Examination Investigations:

Forensic Medical

Reports

What to look at

The whole child Stage of puberty Genitalia Anus

What to look for General trauma Genital/anal:

Trauma Penetration

Complications: Infections STI Pregnancy PTSD

What does it mean

Clinical findings Significance – considers:

Story Clinical findings Investigations

Collection of forensic evidence

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

Completion of J88

Crucial

Child’s story, including date & source

Your story

Treatment Mental

Debriefing Counseling

Physical Treat problems Prophylaxis

Treatment

Injuries Infections STIs Pregnancy

Prophylaxis - infections Within 72 hours Tetanus

ATT STIs

Ceftriaxone Flagyl Erythromycin

HIV AZT & 3TC

Prophylaxis - pregnancy Tanner stage 3+ Pregnancy test Ovral 28 Maxalon

Follow-up

Ensure wellbeing

Known perpetrator Removal

Unknown perpetrator Empowerment

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

EXAMINING CHILDREN

The doctors despair.

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

PROCEDURE

• General examination• Tanner staging• Genital examination

NORMAL GENITAL ANATOMY &

DEVELOPMENT

Chaos & confusion!

FEMALE GENITAL DEVELOPMENT

• 3 phases:• Infancy• Childhood• Adolescence

• 3 features:• Oestrogen levels• Size• Mucosal surface

FEATURES OF SEXUAL ABUSE

The prosecutors despair.

Determining factors• Age:

• Oestrogen profile.• Vaginal environment.

• Nature of Abuse:• Rape • Seduction.

• Acute vs chronic.

• Time lapse:• Short.• Long.

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.

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.

Vaginal penetration Acute genital trauma

Short lived TEARS

Hymenal changes Permanent Stretching Structural changes

J88 & genital anatomy

How to mess with your colleagues mind.

Sections A & B

Story, including date & source.

Crucial

Crucial

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

Section D

Section E

Section F

Indicate what, if any, specimens sent to local laboratory

Interpretation of clinical findings with reasons – not legal finding

Section G

Interpretation of above findings with reasons

Anal penetration

Muco-cutaneous changes TEARS

Dilatation Speed & extent

Venous engorgement Speed

Section H

Drawings

INTERPRETATION OF CLINICAL FEATURES

What does it all mean?

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

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

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)

SUSPICIOUS

• Enlarged hymenal orifice• Posterior hymenal rim < 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

SUGGESTIVE

• 2 or more suspicious anal or genital findings• Scar or laceration of posterior fourchette with

sparing of hymen• Scar in perianal area

CLEAR EVIDENCE OF PENETRATING INJURY

• Hymenal notch between 3 and 9 o’clock• 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 o’clock• Perianal laceration extending deep to external

anal sphincter

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

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

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

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

DEFINITE EVIDENCE OF SEXUAL ABUSE

• Finding sperm of seminal fluid in or on a child’s body

• Witnessed episode of sexual molestation• Nonaccidental, blunt penetrating injury to the

vaginal or anal orifice• Confirmed infection with Neisseria gonorrhoea or

Syphilis

MEAN HYMENAL MEASUREMENTSPediatrics 1992; 89: 393

< 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

MEAN HYMENAL MEASUREMENTSPediatrics 1990; 86: 436

2 – 4 years 5 – 8 years > 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