Transcript HIV/AIDS in Pmb in 2002

Management of Childhood
Sexual Abuse
NEIL McKERROW
Department 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
• College
MMed (…..)
Fellowship (FCP)
Registration
• HPCSA
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•
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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
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Withdrawn & uncommunicative
 Gaining weight
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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

Sarah
3 year old female
 Abnormal social environment
 Abnormal behaviour
 Suspicious examination
 Angry parents
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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
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SAP 308
 Form 4
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Consultation helps
 The system is flawed
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Concepts
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Understand concepts:
Physical abuse
 Sexual abuse
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Dynamics of disclosure:
Spontaneous
 Prompted
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Definition
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Involvement of a child in sexual activity:
Without consent
 Without understanding
 Contrary to norms of society
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Sexual activity involving a child in which
there is a power imbalance
Finkelhor’s perpetrator
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4 stages to abuse:
Desire
 Overcome internal inhibiting factors
 Overcome external inhibiting factors
 Overcome the child
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• Seduction
• Bribery
• Threats
• Force
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
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Welfare:
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SAPS:
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Circumstances & risk of abuse
Crime
Health:
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Explore differential diagnosis/presenting complaint
Support SAPS investigation
Protocol for examination
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Time
Privacy
Consent:
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Parent &/or SAP 308
Child
Participation
Support
System
What to say
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Set the child at ease
Confirm the nature of his/her problem
Explain your role
Explain the procedure:
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Chaperone
Examination
Specimen collection
What to do
History
 Examination
 Investigations:
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Forensic
 Medical
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Reports
What to look at
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The whole child
Stage of puberty
Genitalia
Anus
What to look for
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General trauma
Genital/anal:
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Trauma
Penetration
Complications:
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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
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Completion of J88
Your story
Crucial
Child’s story, including date & source
Treatment

Mental
Debriefing
 Counseling
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
Physical
Treat problems
 Prophylaxis
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Treatment
Injuries
 Infections
 STIs
 Pregnancy
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Prophylaxis - infections
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Within 72 hours
Tetanus
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STIs
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ATT
Ceftriaxone
Flagyl
Erythromycin
HIV
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AZT & 3TC
Prophylaxis - pregnancy
Tanner stage 3+
 Pregnancy test
 Ovral 28
 Maxalon
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Follow-up
Ensure wellbeing
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Known perpetrator
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Removal
Unknown perpetrator
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Empowerment
Hospitals as places of safety
Admit for medical reasons only
 Last resort as a place of safety
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More likely in rural settings
Requires a Form 4
EXAMINING CHILDREN
The doctors despair.
PREPARATION
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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:
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•
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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
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Hymenal changes
Permanent
 Stretching
 Structural changes
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J88 & genital anatomy
How to mess with your
colleagues mind.
Sections A & B
Crucial
Crucial
Story, including date & source.
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
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Muco-cutaneous changes
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Dilatation
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TEARS
Speed & extent
Venous engorgement
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Speed
Section H
Drawings
INTERPRETATION OF
CLINICAL FEATURES
What does it all mean?
CLASSIFICATION OF ANOGENITAL
FINDINGS
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Class 1 - Normal
Class 2 - Nonspecific
Class 3 - Suspicious
Class 4 – Suggestive
Class 5 – Clear evidence of penetrating injury
Pediatrics 1994; 94: 311
NORMAL
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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
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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
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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
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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
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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
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Class 1 – No evidence of abuse
Class 2 – Possible abuse
Class 3 – Probable abuse
Class 4 – Definite evidence of abuse
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Pediatrics 1994; 94: 311
NO EVIDENCE OF ABUSE
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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
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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
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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
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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 MEASUREMENTS
Pediatrics 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 MEASUREMENTS
Pediatrics 1990; 86: 436
Separation
Traction
Knee-chest
2 – 4 years
5 – 8 years
> 8 years
Vertical
5,5 mm
5,6 mm
8,4 mm
Horizontal
3,9 mm
4,2 mm
5,7 mm
Vertical
5,5 mm
6,1 mm
8,3 mm
Horizontal
5,2 mm
5,6 mm
6,9 mm
Vertical
6,3 mm
7,0 mm
8,7 mm
Horizontal
4,6 mm
5,6 mm
7,3 mm