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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) Basic (undergraduate):
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 Specialist
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 MO Nil – 1 year SMO 2 years PMO 4 years Foreign specialist CMO 6 years
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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 Experience Other roles: 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 Attended hospital
Withdrawn & uncommunicative Gaining weight Attended hospital Pregnant Abused over 5 week period Normal genital examination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: Dynamics of disclosure: 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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Finkelhor’s 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: SAPS: Health: Circumstances & risk of abuse
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: Reports 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: Complications: Trauma
Penetration Complications: Infections STI Pregnancy PTSD
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What does it mean Clinical findings Significance – considers: Story
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 Your story Crucial
Child’s story, including date & source
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Treatment Mental Physical Debriefing Counseling 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 Unknown perpetrator Removal
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: Nature of Abuse: Time lapse:
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. Structural hymenal changes:
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 Hymenal changes Short lived
TEARS Hymenal changes Permanent Stretching Structural changes
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How to mess with your colleagues mind.
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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Interpretation of above findings with reasons
Section G Interpretation of above findings with reasons
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Anal penetration Muco-cutaneous changes Dilatation Venous engorgement
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 < 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 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
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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 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
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MEAN HYMENAL MEASUREMENTS Pediatrics 1992; 89: 393
Horizontal 2,5 mm 2,9 mm 3,6 mm Vertical 3,4 mm 2,8 mm 3,9 mm Inferior rim 2,7 mm
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MEAN HYMENAL MEASUREMENTS Pediatrics 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 6,1 mm 8,3 mm 5,2 mm 6,9 mm Knee-chest 6,3 mm 7,0 mm 8,7 mm 4,6 mm 7,3 mm
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