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 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Withdrawn & uncommunicative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
Your story Crucial
Child’s story, including date & source
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
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
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 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
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
