Lawson, G. M.

English

Edinburgh Research Archive

MANAGEMENT OF CHILD SEXUAL ABUSE IN EDINBURGH 1982 -1988 G M LAWSON, M.B., Ch.B. Registrar in General Surgery St Johns Hospital at Howden Howden Road West Livingston West Lothian EH54 6PP Manacement cf Child'Saal Abuse in Edinburgh V ABE-I-7ES Over the last decade, there has been a considerable rise in = =exu=1 abusa to the police surgeons in Edinburgh and the Lothians, This reflect a national and international rise in 1r,m=d=7:2m, described ES rE epidemic and e-7...plosive The reasons For a global i7oraasa ir i7;L:OlLt2 -e=:= 4.-a ;27,71:1E7 hss 12ssm "Clealand -f alleged C.E.A. being Moreover recent reports From 1-as brcL7,t.t 5E7 O7E---- 7 -77:=E7 cf both sides indicate a rie in the actual incidence or of the Atlantic se:4ual abuse in children and adolescents in the past decade.3 Such recent heightened awareness of a problem that has been known For generations, has highlighted the pitfalls of recognition and difficulties in investigation of C.E.A. This has prompted a retrospective analgsis of C.S.A. and its management in g.tliGiclo.ad 21.44 go eouepTouT an.ag. eqq. qoeTga_a gou ñu gcns Ge qng 'sJougne og. GTgeTTuAe 2-72M qeqq. sp..looe.J.TeToTgjo eurq. TT 2 ID eATIlfeque5e_3d3a 9-12 281:-:22 S;LP UT peqonb seJn5Tg eug. ;egg pazTseu,dwG GT gi 'V'9 *0 Jo souepTAG aTqTssod GouepTAG OU 'ecuspTAG eg.TuTgep! _aaLpTe 22 peso; uo pue pessesse eJam esnge rixes O Paci4T.P4TT GLig BuTpJe5ez squepuGgqe @qq = pequewnpop pus ume.ap suoTsnTouo: 'dno35 s5uTPuTg eAT;Tsct, pegeuf.Teep CiS T2r1:422 :0 GAT-4sG55ns 'uoTme, T2qTu2f------u2 GUT s T2DTGLIf .pesF-72ue pue peipu pe,_¡ce2J suo;enTo:_loo pue ';GTTeToeze que7u2;74e enue ' uoT2,2u7ee pue GL174. L-12-1PT7143 TE=TuTri u=G-,y7s 77.-+ =FIn SL,q Lepu-seeez tT .sqTripe zo upTIlepTgTe35 Tr--=es Jog U2TTL .20 esn "_ 2-4.227,C pue p_lcqwe2 Mq "2.24-4 S2M peqdope ..s.3 zo uor4TuTgep egg sMipngs sTqq. go esocLand egg. .2A1s770u7 eesT pue 2961 ug.m.-;Gc, GoTTcd q_lep3o2 puP ueTqqoi egg og. pagoeqqe sucetlans 23TT od pg. peq.acdeJ qTnesse go 2P= g2TT2A9 TT 2 zet44250.4 'pameTAG.3 2.1GM ;Tun Teo-2n9 oT_IlleTpeed TeqTdsoH TS-12U29 U-72 .422M egg. -.4e Sp-J=3J 100q4eW T24Td2014 '(896T-299T) POT .;22M U2A2S 2 JGAO sue1L4-4cl eqq. pue L5.2nquTp3 fif..71_!LTS !>- 290 cases cf alleged C.S.A..were reported in the seven gears reviewed (182-1596), oF which 32(12%) were male and 25Li(66%) were Female. The number cf cases reported per year are'shawn in 1. The primarg rods age preFentai-ion uaa 15 throughout the series. F7CM 158P,h7.17, a hithento ed secondary lower age mode appeared in the 3-5 year old group. By 1588, the last gear of the study, this lower age group BCCOL77=E:1 For 32% of all cases review=,-!.Fir,.1. Lothian Heslzh Board policu regarding alleced C.S.A. has involved a numb=r oF attendant speciaiets ihhn intervie and o'incal examination off 4a% of oases. These specialists included, oento-urirap-, phusicians, ot=i-=trician= end cunaecologists , icrobiolcoL=i-= z=ner=1 and latterl, pasdlatrlo s_rgecns. regarding timing and venue of examination were coordinated by the duty police surgeon who was present in all cases. 163 children (56%) were categorised into the positive Findings group Following examination, 126 children (L13%) showed no signs suggestive oF sexual abuse. Only one child refused an Form oF examination. E5; of males and 60% of Females showed signs consistent with the allegations of sexual abuse. General anaesthesia (6.A.) was administered to 30 patients CIO%) prior to the examination. The paediatric surgeon, who assisted in 5E examinations was the only special st attendant to use G.A. The average age of patient j.,7: -this group was 5:3 uears (range 2 -13 gears) , compared to the series as a whole . Cmean 5.5' pears, range 1- 15 years). 18 children C60 %) showed positive Findings under G.A., 12 CLiC ) had none. All positive Findings in this group would have been detected on examination without G.A. Conclus :ons Cvide supra) regarding the liklihcod cf C.S.A. having =cured were made in 16 C3%) of children examined under G.A., compared to 58 C36o) children assessed without G.A. ?n hoth groups ccllectivelp , the majority conclusion -was that there was no evidence of sexual abuse having occurred. Genera anaes_hesla allowed a more extenelve examination and greater instrumentation and collection of forensic specimens tables 2 and 3). There Was increase sit:'.er hc;;,i°ier .. 5' -^.iFi ránf -` number of additional pos_t_.e phus_cal signs or a return. on F^7=7"'=::: ,.._ter_a,. t...U_1e......CU. P1ctab_ abse--., From _.,e majority of cases were s-_--s severe trauma in the an._.- n . The most con; cr._u described abnormalities were pe.. _nea_ , vulval or introitai inflammation, One or mare r r which were present in 18'e of the positive findings group. Comments regarding signs of hymenal dilatation or perforation were mode in 13% of the positive group and, surprisingly, signs of recant or old eternal humenal trauma were documented in only 12"é. óf cases. Uaginal dscharge C including seminal Fluid in cases) and inflammation were found in 11% and 8% respectively. Throughout the last 5 years of the study, the percentage of children who were Found to have positive signs has remained relatively constant C mean 55 %, range 50- E0°ó), this is in contrast to a redaction in the percentage of examinations on which a- conclusion was drawn, i.e. a drop From 57 to c6': over the ksven gears studied. The paediatric surgeon /police surgeon tears was more likely to draw a conclusion following examination than any other attendant specialist /police surgeon team. Discussion In 1S8i, the Board Regional Comas_ _ _ee advocated an increasing involvement o= the Paediatric Surgeons in cases of alleged C.S.A. This is reFlected in the shift away From examinations in Police Stations,Gynaecology departments and Casualty rooms, towards a more suitable environment -that of the Paediatric Surgical unit. It was considered that the paediatric surgeon would be .Tore Familiar with Female pre- pubertal anatomu.In addition he would hava ready access to general anaesthesia ( originally thought to have a much more important role in assessment of C.S.A.). Much of the recent rise in cases of alleged C.S.A.can be attributed to the recognition of the great importance of the history givenbg the child and the acceptance at a prima facii level of the childs own account and disclosure. In the majority of cases,the history is an important tool in determining whether or riot C.S.A.has occurred. Such is the spectrum of conditions encompassed by the term C.S.A., that only a small proportion of cases have the potential to exhibit any physical findings.DF these, few provide little more than corroborative evidence. B,7a B. Currently, major problem is the lack of normative data on pre- pubertal anatomy. This renders the +assessment and interpretation of perineal findings largely subjective and to a large e :tent based on the e=er -once of the exam' ears . If one considers the childs own account, children seldom ie 1 Pr^`- c=n ho.we,>_-. _ . , _ _ ., - . .. ,, , _ child _s re ea_a_ re encountered if a interviewed and having been fed with inform- -7, -...J jtlrif" `t.: l through .1r questions, G .J=. the at sLbsep-- interviews .Similsrlg, a child who uses adult and sexually explicit terms should be regarded with caution and :uan explanation __tight From the chi._. _,_ : meanino and interpretation attributed to such terms. Levitt advocates a single history taker and examiner- the history to be taken initially with .,then without the primary carer. This aids the gradual transfer of trust,culminating in a relaxed, non -threatening examination. The presence of the 'primary carer can, on occasion, be detrimental to the investigation. A lazg or reticent child may rely on mother to speak on her behalf, or fill in the gaps. In other instances, a child may be reluctant to speak in Front of her parents, because of ernb arrasment 7 or if the primary carer was aware of C.S.A. but of r ed the child little or no protection. The perineal examination should be part of a complete physical medical examination. This affords a more thorough assessment of the child, and is usually better tolerated than a perineal examination alone.Indeed, if we consider the child's perception of the investigation of C.S.A., 25% cf children perceived the the examination to b e just as "bad" as, or distressing as thg initial assault. At what point does a thorough asse ssment of C.C.Â.'become further assault ?. 2 Althcuch a standardised medico -forensic examination for all cases of alleged C.S.A. would seem attractive,it is necessary to match th_ _^`r±Si .ro,r.eSS ánri ávi Snái .onSáS t-ho r.rrFaG i r,na 1 `... r- e':aiu'atic '. ...._tl the le'.el of S:Spic_ in each case. CInde--e--da .t Second Opinion Panel . . im{!creTc of a _,1..r_i...i!t=l ^=_ai l e_ L'r_. ...-_ c. r_- i C The i.,__ cduct_o the ....._. ._. met'li-._ of Ltle prim ar Lg investigation team resu _ted in more .e examinations under general anaesthesia. This allowed For both a more intrusive examination, and collection of more Forensic and micrological samples. Some children underwent examination both with and Significantly, no Further information was obtained G e in the' examinations performed under [ . .. flx p- its ease of instrumentation and access to internal genitalia, no comment was ever made' regarding the state of the vagina in the 30 cases undergoing G.A. Due to the laces or any significant benefit from examination under G.A., the number of G.A.s performed has declined sharply. Indeed , in 1988, general anaesthesia was not used at all in assessing C.S.A. at the Western G¢reral Hospital and we wo'üld conclude that the unly indicatien For general anaesthesia is in assessing the seriously injured child. In the light of recent controversu, it is worth noting that in 2S0 cases of alleged C.S.A., ro mention was ever made of Reflex Anal Dilatation, and hymenal diameter is mentioned less fhán identifying This undoubtedly reflects the difficulty in and interpreting such signs. 9,10 & 11.Indeed, it has been our experience and that of others that the majority of children who have undergone anal dilatation under G.R. as a . treatment ti,G, it. . 1..`:. dietary Hill LJL.aL constipation Ì ct Ìl1 anal L 1 :bü: .LÌ7g. 1 exhibit Few of the manifestations of anal abuse described bu Hobbs and Wynne. 12 In terms of hgmenal slate, such is the wide range uf anatomical variants, that an intact hyena " , esrecias ly the crescentic cr denticulate, not _.:c_ude the __ Uic_tal pe.,_u_i_iun. Ir experience, the use of _._;, e has not s diameter Fluctuates readily during an examination, so an inaccurate measurement does not justify the distress caused in attempting to measure it . The general appearance of the hymen i.e. perforated, dilated or traumatised, would be of greater clinical importance. In those cases where the examiner concluded definite Cr possible C.C.A., hgmenal trauma was the single most common finding, and yet evidence of gross trauma was significantly absent in this series - mild and subtle changes being more commcnplace.he most frequent Finding was that of perineal, vulval or introital inflammation. This must be regarded  one end oF the spectrum oF normality in the pre- pubescant Female perineum. 6,13. The acquisition oF microbiology swats and Forensic samples varied with examiner.Csee table 4 ) The higher number of swats tal:en by the GL+naecologists did not, however, give a higher rate cF conclusions 'as. to the possibility oF C.S.A. Despite the wide range cf swabs and samples collected, ne reference is made to specific seminal markers such as P 30 C seminal glycogen : ,seminal prostagländins or acid pL p: L 3G -1LC..1..5- e , aJ_ i `L ougL spermatozoa identified on microscopy lead to a conclusion f . _ C.S.A. .G u ..- .üii.ü^ Situi: úï LiGL ÌÌlß l_C i.- !'t in 2 cases. The timing of investigations Following alleged C.S.A. will determine the number end type of sample collected, Generally 7? - t t c v...--. _ e_ time -1fÌ'1_t For sperm , -tapes that. spa= ma:. te OrESE!7O a77: _-_..__- _a_le FOr , to 5-10 das raj..aÌ .-c.--.......0 . tatrh..1 'â . The remains a usaï u_ L ..,_.__-. t_ Cs.. Gâ_.....`t "_-. the ....i .f'1 . having occu.red . The find_ c of or .:_t.roLt i swab indicates deFinate C.S.R. The incidence of gonococons teir isolated is diminishing - more often Chlamydia is isolated From vaginal swabs. This reflects the changing spectrum of sexually transmitted disease in the community. lt-t. Over the last decade, we have seen the increasing role of' serology , with particular reference to the H.I.U.virus and sero conversion Cas well as the routine U.D.R.L. screen). Lonclusions The iris,: st.iga:tiOn of C.S.A. in Ediburgh and the Lothians has progreseledsignificantly over the last 7 years reviewed. Audit of the panagemert cf C.S.A. over this period has enabled us to identify certain crucial points; LOCATION. Paediatric Surgical Department EXAMINERS Police Surgeon AND Paediatric Surgeon HISTORY 7 _n;`5?F.I^-rT^P.( -,.:-I::..,ar,- -- This allows corroborative statements to be made and the child only has to endure one examination. The importance of this cannot be over emph- asised . î lost diagnoses of C.S.A. ace made on the history and child's disclosure. The re- sulting index of suspicion will determine the ila .... ' 1..: t i =L. = =ss G\CuII .L ensuing This r eî;ulres a full without the need for r --,_ .77 _. i ̀ . data on pre-pubertal per_ E ns is r.eeded,as well as a standar-di sat_cr L_ anatcii._._ai ^i-! pathological description.The introduction a "Faediatric Rape Kit" would standardise forensic, bacteriology and serology samples taken. The role of the examination team has evolved from simnlu that of a technician providing legally acceptable evidence , to that of an expert witness. The examination team are row being asked to give their opinion - a conclusion- as to whether or not C.S.A. occured. This highlights the importance of having t examiners present,For as we now know, the diagnosis of C.S.A. has Far reaching iiplications and should not be made by one person alone. Im court the presentation of the investigation of each case of alleged C.S.A. should be made by the Police Surgeon (more familiar with court.procedings) and in layman's terms. Should we now challenge Woodling's theory, that whether or not C.S.A.has occurred is for the courts to decide and not a medical diagnosis ? 13 Finally,Future developments of C.S.A. must in the man- uy ement and handling , ng 'progress in two further areas, namely prevention anrl çarl!! rñrnrrnì.ti^?Ì nF children risk. T} ¡r. main this lies in education of both the child and the investigation teams. In West Lothian, a pilot programme has teen introduced entitled "Feeling Yes - Feeling No" This tres around ?_ short t..... _ _. ..._. J:.......+...._ .. .... ... .... the necessary skills that will help otect _hem Fro .. r . F . A . It is hoped that the child, as a result _ entify normal W_i_ ta able to _,__ la..` physical cn_...ct r;J;,:1e and to describe their F`eiings when they are .......... .r... î ii c úia they either like or dislike -"Feeling Yes -Feeling No ". The next aim of the project is to inform the child of who they can approach if they are experiencing "No Feelings ",and to realise that they are not "bad" For seeking help or disclosing their "No Feelings ". In 1588, the Police Woman and Child Unit of Lothian and Eordere Police undertook to Form a special unit of women police officers concentrating on the problem of C.S.A. The function of the unit would be not so múch investigative as supportive. These W.P.C.s would receive Further training in the signs and anatomy of C.5.A., develop interview and counselling skills and og"f er help and support to the child victim during the police phase of the investigation. In addition the unit would serve to provide continuity in liason with other agencies involved in managing suspected C.S.A. REFERENCES 1. 'Hobbs,C.J. and Wynne,J.M. Management oF Sexual Abuse. Archives oF Disease in Childhood 1967, 62, 1162-3487. 2. 7eitlin,H. Investigation oF the Sexually Abused Child The Lancst, Oct 10 1967, 6ii2-61-17 . 3. Feters,E.C., Watt, G.E., Finkelhor,D. A on Child 6exul Abuse. venu Hills, cage Inr!spen,"a:-It Second 4non Panel, Northern F=gicn,--..1 Health Child Seual Abuse : Principles or Good PrabtLbs. British Journal of Hospital Medicine, Jan 1988, S. Eamford,F. and Roterts,R. A B C OF Child Sexual Abuse. British Medical Journal Uol 298, 29 July 1689. B D.H.S.S. Standing Medical Advisor g Committee. Diagnosis of Child Sexual Abuse : Guidelines For Doctors. 1988 London H.M.S.°. 7. Levitt,C.J. Sexual Abuse in Children - A Compassionate Yet Thorough Approach to Evaluation. Post Graduate Medicine, Uo1.80. No 2 Aug 181tV,20121S. 8. ,Hermann-Giddens,N.E.. and Frothingham,T.E. Prepubertal Female Genitalia : Examination For Evidence of Sexual Abuse. S. Paediatrics, Uo1.80. Clauden, 5, Anal Appearances and no:2, Aug 1987, 203-208. Child SPxmal Abuses The Lancet, March 1 1997 , o.PPO. 10. Roberts, R., Sexual Abuse oF rhildrer in Leeds F17-i*i=11 Medical 77=7741, !Jol.292. June 7, 199q, 7.1=P7. 11. qtani-^n,A., Sutherland, R. Prevalence -F ReFla P7a1 Dilatation in 200 ,77ildran. British NEdi2E1 Journal. Uol.PFF, March 23,1E23, 902-3. 12. Hobbs,C.J., Wynne,J.N. Buggery in Childhood - A Common Ey7drome of Chilr! Ahuse. The Lancet, October Li,1S2S, pp7S2-738. 13. Enos,al.F. at al ForenSi Evaluation pF the Sexually Abused Child. Pediatrics. Uol 7P, Sept 1989, nc.3, 38E-99. 1t . Fuster . C . C . , Nein.stein , L . S . :Uayinal Chlamydia Trachomatis: Prevalence in Sexually Abused Pre -pubertal Girls. Pediatrics, Uo1.79, no.8 ,Feb 1987, 235 -23B. TABLE I YEAR 1982 1983 1984 1985 1986 1987 1988 No of alleged cases C.S.A. 4 23 19 40 43 52 103 EXAMINATION TEAM PL.411ca Surgeon Alone 4 13 15 35 32 25 46 Police Surgeon & Gynaecologist - 10 3 3 8 4 18 Police Surgeon & Paediatric Surgeon - - 1 2 l 14 39 Police Surgeon & Paediatrician - - - - 2 7 4 Police Surgeon & General Practitimr;;r - - - - l I Police Surgeon & b4ctgriologist/Senitz' Urirusry - - - - - 1 1 TABLE 2 EXAMINATION & INSTRUMENTATION GENERAL ANAESTHETIC (30 Cases) WITHOUT GENERAL ANAESTHETIC (264 cases) No. CASES % + VE EXAM - VE EXAM NO. CASES % + VE EXAM - VE EXAM External 30 100 18 12 263 99 150 113 Per Vaginal 12 40 9 3 48 10 43 S Per Rectal 16 53 11 5 93 35 47 46 Vaginal Speculum 5 16 4 1 27 10 26 1 Prcctcsccpy 6 20 2 14 3 1 2 1 Vagincsccpy 1 3 1 0 0 11 0 0 . Gutography a 3 . 0 TABLE 3 RECORDED FORENSIC OR MICROBIOLOGY SAMPLE GENERAL ANAESTHESIA WITHOUT GENERAL ANAESTHESIA No. Cases No. Cases M.S.S.U. 1 3 12 4 High Vaginal Swab 13 43 56 21 Anal Swab 11 36 17 6 Urethral Swab 2 6 3 1 Scalp Hair 0 0 32 12 Pubfir, Hair 0 O 31 11 Saliva O 0 26 9 Blood Serology 1 3 30 11 T-:-at Swab '. 3 n. Blood Alcohol 0 0 1 TABLE EXAMINER(S) NO OF CASES EXAMINED TOTAL SAMPLES COLLECTED SAMPLES EXAM Police Surgeon Alone 169 93 0.5 Police Surgeon & Gynaecologist 47 ,7, 1/1 3.6 Police Surgeon & Paediatric Surgeon 52 38 0.7 No.of cases 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 Age Distribution in 1988 (fig. 1 ) 26 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Age in years 

Management of child sexual abuse in Edinburgh 1982-1988

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Management of child sexual abuse in Edinburgh 1982-1988

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