Management of Alleged Sexual Offences in Children

Introduction

Management

Suspicion/Possibility of Sexual Abuse

Management of Paediatric Case of Sexual Abuse

Refer for Counselling

Introduction

When dealing with cases of sexual abuse in children, there is no “choice” in whether a case will be opened with the SAPS, because of the legal obligation to report any case of suspicious child abuse (Child Care Act).

A case of suspected sexual abuse in a child should be investigated by:

• Social Work – risk assessment to be done.
• SAPS – FCS (Family violence, Child protection, Sexual offences unit.
• Clinician– preferably experienced.
  • As in adult cases of alleged sexual offences, there are two aspects in the management of the patient, namely the medical examination (including history, examination and special investigation) as well as a medico-legal examination (including forensic evidence collection if presenting within 72 hours of the alleged incident and completion of the medico-legal documentation – J88 form).

Management

The patient may present to you in several ways:

• During a consultation for other medical reasons, and you suspect possible sexual abuse;
• Referred to be medically examined to investigate the possibility of sexual abuse; or
• With a clear history of alleged sexual abuse

Suspicion/Possibility of Sexual Abuse

(Symptoms or signs suggestive of possible sexual abuse, e.g. genital warts, genital ulcers, vaginal discharge, “redness” of ano-genitalia, pregnancy in children under the age of 16 years, sexualised behaviour or other unexplained behavioural problems, unexplained difficulty in walking or standing (keep in mind differential diagnosis),

When you see a child and a suspicion of sexual abuse exists, but there is no clear history, e.g. child presents with a vaginal discharge, you should take a careful history, do a careful general and genital examination, and document your findings thoroughly in the clinical notes. Consult with a senior colleague or a colleague at a Thuthuzela/clinical forensic unit regarding the genital examination and your findings. If the suspicion is confirmed on medical examination, proceed with further management of sexual abuse (refer to steps below) or refer for a second opinion if you are uncertain about the findings. 

Note: 

Remember the differential diagnosis for paediatric vulvo-vaginitis: 

Non-specific (74% - 80% of cases), vaginal foreign bodies, sexual abuse, sexual transmitted infections, pinworms, lichen sclerosus, psoriasis, eczema, contact dermatitis, scabies, systemic disorders (Scarlet fever, Kawasaki disease).

Management of Paediatric Case of Sexual Abuse

Health care facility staff should report the case to SAPS – FCS unit, if this has not been done yet. 

Note: 

Refer the child urgently to an appropriate level of care if severe trauma or life-threatening injuries are present.  Communicate clearly that evidence has not yet been collected.

FCS detective to provide the attending clinician with:

• A SAP 308 form, signed by the patient/guardian and investigating officer. (This form gives the clinician consent to perform the examination, collect evidence, and to release the completed J88 form, which contains confidential medical information to the investigating officer)
• Sexual assault evidence collection kit(s) with J88 form (if the alleged offence occurred within 72 hours of presentation, and it is indicated by the history of the alleged incident)
• J88 form (if the alleged offence occurred more than 72 hours before presentation)
• Affidavit 212 form

The following steps should be followed in the management:

If the alleged incident occurred within 120 hours of the alleged incident, the child must be seen as an emergency and priority case.  If the alleged incident occurred more than 120 hours after the alleged incident, the child should be seen as soon as possible, preferably during normal office hours, when a multi-disciplinary team is available.

Provide containment counselling if available on site:

• Explain the purpose of the examination and ensure privacy.
• Prepare them for the possibility of having to collect forensic specimens.

History taking:

• Document in your notes who provides the history (e.g. patient, or third party).
• Take the history, as appropriate, as this will guide your examination, collection of forensic evidence and to aid the interpretation of clinical findings.
• Be careful not to include too much non-medical detail, such as exact dates and times on the J88, as this may differ slightly from the formal statements – refer to section on the completion of the J88 form.

General physical examination:

• Exclude concomitant physical abuse and/or neglect.
• Document all injuries in detail, and indicate position and extent on body diagrams on page 4 of the J88. Use the correct terminology when describing wounds, and try to describe the age of any wounds in general terms (i.e. fresh, healing, old/healed, or scar).
• Take note of the pubertal development (Tanner stages).
• Remember to examine the clothing as well and document significant findings on the J88 form.  Collect the clothing as forensic evidence, using the appropriate evidence collection kit, if any possible body fluid or blood is seen on the clothing.

Genital and anal examination:

• The genital examination should ideally be performed once only.
• Small children can be examined on the mother’s lap, with the back to the mother holding the legs, or alternatively on the examination bed in the supine frog-leg position.
• Older children can be examined in the supine lithotomy position.
• If an injury/abnormality is noted, the child should be re-examined in the knee-chest position. Document the examination position on the J88.
• Utilize the lateral decubitus position to examine the anus.
• If the child is anxious and refusing an examination, the value of examination under anaesthesia should be discussed with a senior colleague.  If severe anogenital injury is noted, the child should be examined in theatre under anaesthesia.
• Reveal only the part of the body that is being examined, and cover the rest with a sheet.
• Expose the female genitalia by gentle labial separation and lateral traction on the buttocks or labia majora.  Digital internal examination is never indicated in the prepubertal child.
• Examine the external genitalia (labia majora and minora, clitoris, vestibule, posterior fourchette, fossa navicularis and perineum) for signs of acute trauma.
• Examine the “internal” genitalia (hymen and vagina) for signs of acute trauma as well as any structural changes suggesting penetration.
• Examine the genitalia carefully and describe the injuries.
• Describe the hymen: appearance, shape, presence of oedema and inflammation, clefts, irregularities, lacerations (record position).
• Anus: examine the anal tone, look for reflex dilatation, fissures or tears (record position), bruising (do not confuse with dilated blood vessels). It is inappropriate to do a rectal examination.

Collection of forensic specimens:

• Collect if patient presents within 72 hours of the alleged incident, if indicated by the history.
• Follow the guidelines provided in the information booklet, contained within the sexual assault evidence collection kits.

Collection of specimens for medical purposes:

• Rapid HIV test with pre- and post-HIV test counselling, and with consent.
• Rapid RPR test.
• Urine pregnancy test in female children with sexual development of Tanner stage 3 or higher.
• Further screening for STIs, if indicated.
• A Hepatitis B test should only be requested in those children who are not completely immunized or where the immunization status is unknown.
• Full blood count and ALT if antiretroviral medication is prescribed.

Documentation of findings:

• Document your findings in the clinical notes.
• Complete the legal documentation in duplicate – J88 Form, Evidence collection form, and Affidavit 212 form; seal the top copy of the Evidence collection form with the collected evidence in the kit, and hand the original J88 form to the investigating officer. 
• Retain copies of the legal documentation in the patient’s folder.

Provide treatment and prophylaxis as indicated

• Treat all acute injuries and infections evident on presentation, and refer to the appropriate level of care if indicated.
• Treat established complications – infections or pregnancy
• Prophylaxis
  • Infections:
    • Anti-tetanus toxoid: ½ cc IMI if skin or mucosal barrier shows a significant tear; and depending on vaccine status (if available).
    • Ceftriaxone: <12 years 125mg IMI stat or 12 years and older 250mg IMI stat
    • Metronidazole
    • 1-3 years 50mg 8-hourly for 7 days
    • 3 – 6 years: 100mg 12-hourly for 7 days
      • 7 – 10 years: 100mg 8-hourly for 7 days
      • 11 years and older: 200mg 8-hourly for 7 days
      •  <8 years:
      • Azithromycin 20mg/kg single dose stat (maximum 1g) OR
      • Erythromycin 10mg/kg 6-hourly for 7 days (if still in stock at hospital) OR
      • Clarithromycin 10mg/kg 12-hourly for 5 days
      • 8 years and older:
      • Azithromycin 20mg/kg single dose stat (maximum 1g) OR
      • Doxycycline 100mg 12-hourly for 7 days
  • Anti-retroviral prophylaxis
    • HIV positive (confirmed)
    • Refer for further counselling and HIV case
    • HIV negative* – see table below

• Emergency contraception, for all girls with physical maturity of Tanner stage 3 or more:
  • 1^st choice: Escapelle (1.5mg Levonogestrel) 1 tablet stat po
  • (If not available: Ovral 2 tablets immediately and 2 tablets after 12 hours, OR stat OR Norlevo 2 tablets stat)
  • Add anti-emetics:
  •  5 – 14 years: Metoclopramide 5 mg tds po, take 30 minutes before eating
  • >14 years: Metoclopramide 10 mg tds po, take 30 minutes before eating
  • Repeat dose of emergency contraception if vomiting occurs within 2 hours after taking.
  • Increase dose with 50% if patient is already on any liver-enzyme inducing medication. e.g. Escapelle 2 tablets stat OR Norlevo 3 tablets stat OR Ovral 3 tablets stat and 3 tablets 12-hours later
• Simple analgesia
  • Offer simple analgesia if indicated, e.g. Paracetamol.

Refer to social worker if not already done and ensure child is safe. (Arrange for hospital admission if child unsafe, and no immediate place of safety available)

Refer for Counselling

• Arrange follow-up visits (2 weeks, 6 weeks and 3 months)
• At the follow-up visit(s):
  • Document whether the child or caregiver experience any post-traumatic stress syndrome symptoms at each visit, and give advice regarding medication and blood results.
  • Ensure that arrangements for counselling are in place.
  • A repeat physical examination is only required if there was significant injury and documentation regarding healing is required.
  • Follow-up blood results on Hepatitis B serology (if this was indicated) and manage accordingly.
  • Repeat Full blood count at 2 weeks, if on antiretroviral medication, to monitor for anaemia.
  • Repeat HIV and RPR tests at 6 weeks and 3 months.
  • Enquire about menstruation and repeat pregnancy test if indicated at 6 weeks and 3 months.
  • Investigate and treat sexually transmitted infections.
  • If survivor becomes pregnant as a result of the alleged rape, and wishes to terminate the pregnancy, she should be referred to an appropriate health care facility for a safe termination of pregnancy as soon as possible.

References

• McKerrow NH. Step-by-step guide for the management of sexually abused children. Department of Paediatrics Pietermaritzburg Metropolitan Hospital Complex Kwazulu-Natal.
• Paediatric Case Management Guidelines: Updated management of child abuse – circular H2/2006.  Department of Health Western Cape.
• Van Eyk N, Allen L, Giesbrecht E et al.  Pediatric Vulvovaginal Disorders: A Diagnostic Approach and Review of the Literature.  J Obstet Gynaecol Can2009;31(9):850-862