1. The Role of the Paediatrician in the Medical Examination for Suspected Child Sexual Assault
Medical Student Teaching
Dr Jo Gifford
Clinical Lead, WMpSAS
Designated Doctor Child Protection, Coventry
Consultant Community Paediatrician CWPT

2. Talk Overview Background on CSA How do children present?
The “CSA Medical”
What are we looking for?
Forensic swabs
Trigger warning

3. Definition of CSA Safeguarding Children: Working Together under the Children’s Act
Sexual Abuse involves forcing/enticing a child or young person to take part in sexual activities
whether or not the child is aware of what is happening.
the activities may involve physical contact or non-contact activities, or encouraging children to behave in inappropriate ways.

4. Child Sexual Assault/Abuse compared to adult sexual assault
More often repeated over time (chronic) than single acute assault event
Often delayed disclosure or no disclosure
Perpetrator within close family/friend circle
Adolescents most likely age-group to present adult fashion
History taking not limited to alleged event  safeguarding assessment

5. Sexual abuse Across socioeconomic boundaries Boys and girls
Birth-adulthood
Male and female perpetrators
Child perpetrators
Most abusers within family or close circles
Internet becoming a major factor
Child may become complicit (grooming)

6. Vulnerable groups Non-biological care-giver Children in Public Care
Step parent
Disabled children
Chaotic families
Parental addiction/prostitution/destitution
Parental mental health problems
Domestic violence
Unmonitored Internet access
Types of abuse overlap: subject to one, at risk of another

7. Presentation of Sexual Abuse
1. Disclosure
Specific or Non-specific
Age-related
Historical
2. Behavioral/psychological disturbance
3. Physical indicators

8. 1. Disclosures Age-related May “test the water” with lesser disclosure
May be difficult to interpret in young children
May “test the water” with lesser disclosure
Often retract or change
Fear of consequences for self or family
Threats by perpetrator
Grooming

9. 2. Behavioural/Psychological
Sexualized
Over-friendly
Anxiety, fearful
Withdrawal
Hyperactivity
Depression
Low self esteem
Acting out
Self-harming
Learning
School problems
Regression
developmental delay
Somatic complaints
Sleep disturbance
Food-refusal, mutism
Wetting, soiling
Recurrent abdo pain
Recurrent Headache

10. 3. Physical symptoms Unexplained vaginal or anal bleeding/injuries
Bruising, bites, scratches
Pregnancy
STI
Recurrent vaginal infections or UTI
Pain in the anal or genital area
Recurrent atypical abdominal pain

11. Differential Diagnosis
Normal variants
Nappy rash
Straddle/accidental injury
Haemangioma
Lichen sclerosis
Eczema
Adult interpretation of innocent event
Threadworms
Vulvovaginitis
Mongolian blue spot
Vertical transmission or autoinoculation of STIs
Childhood self-gratification /normal behaviour
Anxiety not due to abuse

12. Normal behaviour or sign of CSA?
5 year old girl who coloured in her labia with a felt tip pen
7 year old girl put red felt tip on her pants repeatedly
4 year old boy upset female cousins showing genitalia “I can roll my willy into a snail”
3 year old boy got erect penis stuck in bubble wand in bath
3 year old boy said step-father “waggled his wigger at me”. Step father said “teaching him to pee like a man”
6 yr girl sticks a toothbrush up her little brother’s bottom
2 year old girl “humping everything”

13. What to do if concerned? Consider asking child/young person or carer
Age-appropriate language
Open questions
Write disclosures down verbatim
Discuss with experienced doctor/safeguarding lead
Refer for multiagency safeguarding assessment
Children’s Social Care  MASH
+/- Police
Specialist Examination

14. Confidentiality
“If a child or young person under 16 refuses consent, doctors should nevertheless disclose the information if this is necessary to protect the child, young person or someone else from serious harm, or if disclosure is otherwise justifiable in the public interest. In the context of what might amount to a serious sexual offence involving a child, a doctor would have to be particularly alert to the possibility of other children who might be at risk. “ MPS

15. Voluntary Sexual Activity & the Law
Non-consensual sexual activity is a crime regardless of age.
UK Age of consent is 16 (regardless of orientation & gender)
Professional response to voluntary sexual activity:
Obligate reporting of any sexual activity under 13yr
13-16 yr risk assessment
Consideration of possible CSE including 16+

16. CSA Specialist Examination

17. What happens in the SARC
Child/YP and family supported by crisis worker
Specialist paediatrician/FME
History
General examination
Genital examination using colposcope
Aftercare
Forensic exam = 3-6 hours
“Your body, your choice”

18. Examination – WHY? Evidence (including historic cases) Health
Identify & treat injuries
Screen STIs, Hep B immunise, HIV PEP
Emotional assessment & Therapy
Emergency contraception
Baseline assessment
Reassurance

24. Examination Position 2
Prone (Knee Chest) – Pre pubertal only

25. Genital Anatomy

27. Partial Laceration

28. Deep Notch

29. “Normal” anatomy doesn’t mean nothing happened
Physical examination alone rarely diagnostic
Physical signs often absent even when perpetrator admits (Adams, 1994 Muram, 1989)
Most forensic information is at scene of crime (pre-pubertal children) not on child

30. FORENSIC SWABS Gently roll the swab Do not rub the tip
the harder you rub, the more donor DNA is picked up.
Yes
NO!

31. DNA FACTS Forensic samples Mouth 31 hours Penis 2 days Vagina 7 days
Semen can
Survive in a 40° wash
Remain indefinitely on clothes (one case cracked after 25 years!)
Be detected in urine up to 48 hours after intercourse
Forensic samples
Mouth 31 hours
Penis 2 days
Vagina 7 days
Anus 3 days
All forensic evidence will gradually be lost
Typically perpetrator DNA will only persist for
2 – 3 days on young children
5 – 7 days teenagers
Offender DNA on a victim’s skin 48 hours after incident (if not washed)
Victim DNA on offender’s fingers up to 24 hours

32. What else does the Paediatrician do?
Evidence-based Report – average 5-6 pages
Professional/Expert Witness
So Dr Gifford,
Does your examination confirm the allegation?

33. Forensic Training Increasingly regulated Initial training course
Supervised on-job training (as senior trainee or consultant)
FFLM membership/licence exams

34. Take-home messages
CSA presents in a wide variety of ways – many non-specific
All ages; boys and girls
DNA evidence is time sensitive
Normal anatomy does not exclude CSA
Highly specialised examination
Examination generally well tolerated by children and young people

35. Final Thought…
Done well, the examination itself can be therapeutic