THE MEDICAL MANAGEMENT OF ACUTE & CHRONIC CHILD SEXUAL ABUSE:

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Griffin Scott
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1 THE MEDICAL MANAGEMENT OF ACUTE & CHRONIC CHILD SEXUAL ABUSE: THE BALANCE BETWEEN MEDICINE, FORENSIC NEEDS & PSYCHOLOGICAL FIRST AID NEIL MCKERROW KZN DEPARTMENT OF HEALTH

2 PURPOSE Medical assessment Explore differential diagnosis / Confirm abuse Exclude complications / sequelae Treat problems Prevent sequelae Support legal process J88 SAECK

3 PRINCIPLES Best interest of child NOT caregiver or system Participation of child Requires consent / assent Holistic care Basic treatment even if unable to assess Assume the worst to achieve the best

4 CHALLENGE Modes of presentation Acute Delayed Incidental System Capacity Access Delays Features & behaviour of Child NORMAL

5 EXPECTATIONS VS REALITY System expects medical evidence to support claims of sexual abuse Medical examination can sometimes confirm but never exclude sexual assault in children IT S NORMAL TO BE NORMAL

6 FEATURES OF SEXUAL ABUSE Forensic specimens Injuries Structural changes Sequelae Physical Psychological

7 FORENSIC EVIDENCE Semen in 9-20% 90% within 24 hours 81% adolescent Prepubertal - only on clothes Blood Body 13 hours Semen Clothes 24 hours Body 9 hours WINDOW OF OPPORTUNITY HOURS

8 PSYCHOLOGICAL Short term 2 o to violence Long term 2 o to betrayal 2 o to adversity PTSD Behavioural problems

9 PHYSICAL EVIDENCE Overall 20 30% Acute injuries 5-30% Structural changes < 20% Sexually transmitted infection <5% Pregnancy 1.5% of adolescents Increased with history of Pain Bleeding

10 CLINICAL FINDINGS IN ALLEGED SEXUAL ABUSE PARADISE 1990, PEDIATR CLIN NORTH AM 37:

11 Normal examination does NOT mean nothing happened Kellog (Pediatrics 2004) 36 pregnant teenagers Mean age 15,1 years 22 (64%) normal / nonspecific examination 2 (6%) definite evidence of penetrating injury

12 WHY? 2 o to dynamics of childhood sexual abuse: The perpetrator The process of abuse The process of disclosure The intrinsic properties of the female genital tract

13 PROCESS OF ABUSE Faller Power imbalance Finkelhor Desire Overcome internal inhibitions Overcome external inhibitions Overcome child POWER IMBALANCE Coercion Manipulation RAPE SEDUCTION

14 PERPETRATOR Desire Relationship vs sexual intercourse Relationship Rule of ¼ Most children abused by someone they know likelihood of seduction physical trauma psychological trauma (long term)

15 PROCESS OF DISCLOSURE Coercion Seduction Fear Confusion Delayed disclosure Only suggestion Structural change Sequelae Poorer recall Healed injuries

16 DYNAMIC GENITAL TRACT Growth & development: 3 phases / ages: Infancy * Childhood Adolescence * Implications: Size Function * Environment * *

17 OESTROGEN Makes sex possible Protective: Leukorrhoea Lubrication abrasions Elasticity Flexibility tears Growth Masks pre-existing structural changes

18 SO.. BALANCE Psychological sequelae inevitable Physical needs variable Forensic evidence unlikely HOWEVER Physical evidence increases success of litigation

19 THEREFORE Child s needs always 1 st Psychological before physical Medical assessment is seldom an emergency Cannot examine without consent/assent Examine only when child ready Prepare for assessment If indicated treat regardless of assessment

20 MEDICAL ASSESSMENT Obtain history Explore differential diagnosis Identify - features / complications of abuse Collect forensic evidence. Prevent sequelae of sex - PTSD / STI / Pregnancy Support legal actions. Ensure ongoing safety & wellbeing of child

21 MEDICAL CARE IN 6 STEPS 1. Suspect 2. Investigate 3. Validate 4. Treat 5. Ensure safety 6. Ensure support

22 SUSPECT What you hear: Allegation of abuse by the child, a co-abused, the perpetrator or a 3 rd party Symptoms Physical - urinary tract symptoms, lower abd pain, vaginal discharge etc Psychological - sleep disturbance, appetite changes, flashbacks What you see: Behavioural problems, sexualized language or behaviour What you find: Genital/anal injuries, infections, structural changes

23 INVESTIGATION Medical assessment Explore differential diagnosis/presenting complaint Forensic assessment Support SAPS investigation J88 - always Sexual Assault Evidence Collection Kit (SAECK) Biological specimens 24 hours Corroborating evidence 72 hours

24 REQUIREMENTS Time At least 90 minutes Timing Within 72 hrs of abuse immediately More than 72 hrs after abuse at convenience Privacy Visual & auditory Limit exposure to traumatic experiences Facility

25 WHEN Early presentation (within 72 hours): During the day or early evening ASAP Late at night (after 22h00 Exclude acute trauma requiring immediate care. Start prophylactic treatment. Put the child to bed. Arrange for a full assessment first thing in the morning. Delayed presentation (after 72 hours): At leisure Multidisciplinary team

26 EMERGENCY (IMMEDIATE ASSESSMENT) Genital or anal pain Evidence of genital or anal bleeding or injury At extreme of 24 hour window for collection of forensic evidence

27 PREPARATION Essential for Cooperation Consent Reducing 2 o trauma Support Chaperone Drapes

28 CONSENT For examination From the child From the parent / guardian From the SAP (308) Additional: Disclosure SAECK & J88 HIV test ART R x

29 MEDICAL ASSESSMENT History A process Examination 3 stages General Pubertal Anogenital Special investigations Focus on complications Pregnancy & STIs

30 EXAMINATION Genital 2 positions Supine Knee chest 2 techniques Labial separation Labial traction Toddler: Mom s lap Internal examinations are NEVER indicated Anus Always

31 TREATMENT: MENTAL Prevent: PTSD by debriefing The earlier the better Treatment: Look for PTSD persistence of S x following incident If present - refer

32 TREATMENT: PHYSICAL Treat problems evident on presentation: Acute injuries Established complications Infections STIs Pregnancy

33 PHYSICAL: PROPHYLAXIS On allegation of abuse Within 1 week of abuse (72 hrs for HIV PEP) Infection ATT ½ cc IMI if skin or mucosa breached STIs Ceftriaxone < 45 kg 125 mg IMI stat > 45 kg 250mg IMI stat Metronidazole 7mg/kg/dose tds for 7 days Erythromycin 50mg/kg/day qid for 7 days HIV

34 ART DOSES Offer PEP: On suspicion of penetrative abuse Presentation is within 72 hours of abuse After confirmation of HIV -ve status Regimens Basic AZT & 3TC Expanded add Kaletra if: A breech of skin or mucosal surface Anal penetration Multiple perpetrators

35 R x Ovral 28 / Norleva PREGNANCY PROPHYLAXIS Up to 7 days post assault Tanner stage 3+ thelarche regardless of menarche Pregnancy test -ve Maxalon Follow-up

36 FOLLOW UP 48 hours: HIV Elisa result if rapid tests were discordant Physical & emotional wellbeing 1-2weeks: Emotional wellbeing Check for physical complications of abuse: Sexually transmitted infections Pregnancy Results of baseline blood tests 3 months: Repeat bloods to exclude syphilis or HIV infection

37 ENSURE WELLBEING Create a protective environment: Ensure child safe from ongoing abuse Understand process of abuse (Finkelhor) If possible separate child & perpetrator Known perpetrator removal of perp Unknown perpetrator empowerment Implement adequate supervision Female Safety in numbers

38 FAMILY RECONSTRUCTION Child s primary support system Maintenance of support systems Functional family functional child

39 CONCLUSION Medical assessment is seldom urgent Psychological care is a priority Medical treatment may be urgent Pain & bleeding Prophylaxis within 72 hours 1 week Forensic evidence is only relevant within 24 hours

Sexual Abuse. Dr Burke Baird

Sexual Abuse. Dr Burke Baird Sexual Abuse Dr Burke Baird Unlike physical abuse, where you are typically faced with a suspicious injury and you go looking for an explanation, with sexual abuse, you usually start with a verbal disclosure