Forensic Skills for Primary Care Clinician

1. Forensic Skills for Primary Care Clinician Dr K BALACHANDRAN Retd. Consultant Community Paediatrician 26th July 2012

2. Forensic Skills for Primary Care Clinician • Recognition • Assessment • Referral Pathways • Identification of Further Learning

3. Key Learning Points • Common Clinical Presentation at GP Surgery • History Taking • Consent Issue • Risk Assessment/Examination • Documentation and Record Keeping • Awareness of Referral Pathway • Communication with the child and Parent/s • Communication with other agencies

4. Cleveland Enquiry 1987 The report of the Enquiry into Child Abuse in Cleveland 1987 (Butler-Sloss, E. 1988)(9) summarised, 'We have learned during the Enquiry that sexual abuse occurs at all ages, including the very young, to boys as well as girls, in all classes of society and frequently within the family'. The abuse was found to include oral, anal and vaginal penetration. Contact - touching , oral contact of breasts, genitalia or anus, masturbation inserting digits or objects into vulva & anus rape with attempted/achieved penetration of vagina or anus oral penetration Non-contact - exhibitionism pornography erotic talk Physical injury may be part of the sexual assault, e.g. bites on the breasts or sadistic burns on areas as seen in non-sexual assault.

5. CSA Definition • Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, whether or not the child is aware of what is happening. The activities may involve physical contact, including assault by penetration (for example, rape or oral sex) or non-penetrative acts such as masturbation, kissing, rubbing and touching outside of clothing. • They may also include non-contact activities, such as involving children in looking at, or in the production of, sexual images, watching sexual activities, encouraging children to behave in sexually inappropriate ways, or grooming a child in preparation for abuse (including via the internet). • Sexual abuse is not solely perpetrated by adult males. Women can also commit acts of sexual abuse, as can other children. Working Together to Safeguard Children HM Gov March 2010

6. Child Sexual Abuse • CSA may present in many ways • Some may be picked up by social workers during section 47 enquiries • Others may present medically with concerning signs and symptoms and referred by GPs and HVs • The abuser frequently grooms and threatens children so that a clear disclosure is not often made at an early stage in the process • There are very few absolutely diagnostic signs

7. Child Sexual AbuseConcerning signs and symptoms • Vaginal bleeding • Rectal bleeding • Vulvo-vaginitis • Ano-genital warts • Masturbation • Foreign body in anus/vagina • Genital mutilation • Soiling/bowel disturbance/enuresis • Behavioural presentation • Pregnancy in child • STD – chlamydial and gonococcus • Presence of semen/sperm

8. Differential Diagnosis • Accident e.g. straddle injury, cross-bar • Early onset of puberty (girls) presenting with bleeding • Congenital abnormality, e.g. septate hymen • Infection e.g. streptococcal • Infestation e.g. thread worms • Skin disorder e.g.. Lichen sclerosis, eczema • Inflammatory bowel disease, e.g. Crohns disease • Rectal polyp presenting with bleeding • Severe constipation leading to an acute anal fissure.

9. Child Sexual AbuseHistory • Bowel and urinary history • History of genital/anal symptoms • Behavioural changes • Check menstrual and sexual history in adolescents • Disclosure of sexual abuse – Police/Children’s Social Care Interview – anything disclosed by the child may form evidence in court

11. Child Sexual AbuseExamination • Examination of the ano-genital area of a child may be included as part of the routine examination and would certainly be essential in many clinical situations • Consent of the parent/child is important • Suspected CSA examination requires a doctor with specific expertise and training, and preferably with facilities for use of colposcope and photodocumentation,STI and forensic testing as appropriate

12. Child Sexual AbuseOther aspects of Examination • Examination technique and skills in carrying out such examination • Taking appropriate swabs for STIs • Where appropriate taking forensic swabs, paying attention to the chain of evidence ( to prevent contamination – any one handling the sample will need to sign and date the form)

13. Child Sexual AbuseClinical Management • Having taken all relevant forensic swabs and swabs for STIs, it is essential to prescribe emergency contraception and prophylactic antibiotics for STIs indicated • Other aspects will include – management of neglect issues, failure to thrive, poor relationship issues, infections, immunisations (HepB), drug/alcohol abuse, family planning • The possibility of HIV infection will need to be considered, discussed with child/parent/carer, investigated and managed appropriately. Seek advice from your local virology/GUM department

14. Indications where a child sexual abuse medical should be considered: • Where a sexually transmitted infection or pregnancy is found in a child. • Anogenital warts – though there can be vertical transmission, a significant proportion of warts are associated with sexual transmission and therefore a sexual abuse medical must be considered. • Where signs of a problem such as recurrent vaginal discharge, genital bleeding, secondary enuresis occur in conjunction with a relevant history of concern. • Where a child or someone else alleges the child has been sexually abused/raped/assaulted etc. • Where there are signs of injury that may cause concerns, such as a genital injury. *Adapted from “The Physical Signs of Child Sexual Abuse” Royal College of Paediatrics & Child Health

15. Indications where a child sexual abuse medical should be considered: • When there is evidence of physical abuse, emotional abuse or neglect. • When there is a behavioural disturbance e.g. actual or threatened self harm, inappropriate sexualised behaviour, encopresis, aggression, cruelty to other children or animals, substance misuse, eating disorder, in conjunction with a relevant history of concern • When there is a history of “worrying” contact with a sexual offender • When the child is a sibling or friend of an index child • However not all children will require a child sexual abuse medical examination. Some teenagers, for example, may engage in regular voluntary sexual activity. Others may have an isolated behaviour problem such as an eating disorder, substance misuse etc. *Adapted from “The Physical Signs of Child Sexual Abuse” Royal College of Paediatrics & Child Health

16. Parents/Child Police Health Referral process Education Social Care Comprehensive paediatric assessment Strategy Discussion Definite or possible abuse Immediate Management Joint Paediatric Forensic Exam Specialist Exam Admit to ward if necessary Ongoing Management-Nominated Consultant Paediatrician (Hospital/Community) • Social care • Case Conference Legal Action Medical Care/Follow-up/Counselling

17. Possible Outcomes of Strategy Discussion • No action required from a medical perspective • A comprehensive paediatric health assessment • A child sexual abuse examination – consent for photodocumentation, venue, who, when, how and preserve chain of evidence • In case of professional disagreement between health/social care/police how to address such issues

18. Future Learning • Training issues • Shadowing the work of colleagues • Preparation of a practice based protocol or clinical care pathway in conjunction with experts

19. Thank You