management of childhood sexual abuse neil mckerrow department of paediatrics pmb metropolitan...
TRANSCRIPT
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Management of Childhood Sexual
Abuse
NEIL McKERROWDepartment 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Withdrawn & uncommunicative Gaining weight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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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:
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
Child’s story, including date & source
Your story
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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
Story, including date & source.
Crucial
Crucial
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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 < 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 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
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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