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Abstract
Introduction A perception exists that there are few benefits of a paediatric assessment in historic child sexual abuse (CSA), as the likelihood of finding forensic evidence is low.
Aim To determine the value of a comprehensive paediatric assessment in a dedicated clinic for children and young people who present following suspicion or allegation of historic CSA.
Method All children with suspected or alleged historic CSA, defined as >7 days after the last episode of sexual assault in pubertal girls, or >3 days for prepubertal girls and all boys, were assessed in a specialised paediatric clinic. Clinic data were collected prospectively between October 2009 and November 2014 and through retrospective case note review.
Results Among the 249 children who presented with possible historic CSA, ages ranged from 0 to 17 years (median 7, SD 4.3). Of these children, 141 (57%) had a medical concern(s) related to the referral reason, 78 (31%) had an unrelated medical concern(s) and 55 (22%) had emotional or behavioural concerns requiring onward referral, while 18 (7%) children had physical signs supportive of CSA. Findings referable to social care were identified in 26 cases (10%), the police in 6 cases and 15 (6%) parents required professional help for anxiety symptoms.
Conclusions This study highlights the value of a comprehensive paediatric assessment in a dedicated clinic for cases of suspected or alleged historic CSA, by identifying a broad variety of unmet health needs in this group. The findings have important implications for the child, their families and the multiagency team.
- historic child sexual abuse
- multiagency
- unmet health needs
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What is already known?
In the majority of cases, including those presenting acutely, children and young people examined after sexual abuse will have a normal physical examination.
Following the Cleveland Inquiry in the UK, there can be a reluctance to refer such children for a paediatric assessment.
Previous literature has found associations between poor health and child maltreatment generally, but few studies have focused on the health needs of sexually abused children.
What this study adds?
Children and young people with alleged or suspected historic sexual abuse merit a comprehensive paediatric assessment by appropriate professionals.
Such children may have many unmet health, emotional and developmental needs, which inform multiagency planning.
Significant physical signs of sexual abuse may be present beyond the forensic timescale for physical examination.
Introduction
There are approximately 11.5 million children and young people (CYP) in England with estimates that over a 2-year period, there were 425 000 victims of child sexual abuse (CSA), but only 1 in 8 came to the attention of statutory agencies.1 Many children delay disclosure of CSA even into adulthood. Large-scale studies of CSA disclosures among adolescents and adults found that less than a quarter of victims presented in the first 24 hours, and the majority over a month to more than a year later.2 Delay in disclosure may be due to children not recognising their abuse until much later, potentially influenced by grooming, intrafamilial abuse or multiple incidents over time.3–5 The breach of trust experienced by victims has long-term effects on physical and mental health.1 ,6
The Cleveland Inquiry in the UK found doctors examined children inappropriately and misinterpreted the physical signs of CSA.7 The legacy from this inquiry contributes to the view that an ‘intimate examination’ may ‘repeat the abuse’8 and in our experience dealing with multidisciplinary professionals, we sense ongoing reluctance to refer for a paediatric assessment. However, it has been shown that medical assessments are useful across the full spectrum of maltreatment.9
It is well recognised that a normal anogenital examination does not exclude the possibility of sexual abuse as the majority of children, even those presenting acutely alleging vaginal or anal penetration, will have a normal examination.10–13 Reported signs vary from as low as 4% in cases of possible CSA11 up to 38% in those alleging penetrative abuse.14 With regard to the timing of the examination, the benefit of a late physical examination (box 1) is questioned due to the low yield of forensic findings, thus decreasing the likelihood of criminal prosecution.15 However, signs persisted in 25% of those examined 7 days after alleged penetrative abuse, and up to 30 days after genital injury, well outside the forensic timescale for intimate body specimens.14 ,17
Key timescale definitions in presentations of CSA
Acute presentation of CSA: This is a presentation that is within 7 days of the last episode of sexual assault in pubertal girls, or within 3 days for prepubertal girls and boys of all ages, which is when forensic findings in the form of intimate body specimens are more likely to be positive.16 Specimens must be obtained within these timescales.
Historic presentation of CSA: This is a presentation that is more than 7 days after the last episode of sexual assault in pubertal girls, or more than 3 days after the last episode for prepubertal girls and boys of all ages. Forensic specimens cannot be obtained beyond these timescales.
CSA, child sexual abuse.
The Royal College of Paediatrics and Child Health (RCPCH) provides evidence-based guidance for identifying physical signs in CSA.16 ,18 This suggests clinicians perform a child-centred assessment, in keeping with the United Nations Convention on the Rights of the Child.19 The value of a medical examination has been explored both in the USA and UK, although these clinics had a mixture of acute and non-acute presentations.9 ,20 Therefore, the value of a paediatric assessment in historic abuse warrants exploration.
This study aims to determine the value of a paediatric clinic for CYP who present following a suspicion, or allegation of historic CSA. There are few such dedicated clinics in the UK. The purpose of the clinic is to comprehensively assess CYP with potential historic CSA, and to provide medical treatment, advice and follow-up for CYP and their caregivers. We explore the spectrum of unmet health concerns, which will potentially inform the multiagency team as to the broader merits of an assessment from the health, social care and legal standpoint, as well as informing practice and policy in this area.
Methods
Study population
Prospective data were collected on a case series of all CYP aged 0–17 years completed years presenting to the historic CSA assessment clinic at the University College London Hospital (UCLH), UK, during a 5-year period from 9 October 2009 to 26 November 2014. This work was deemed exempt from ethical approval requirements, as it was an audit approved by the UCLH clinical governance team. All data were anonymised in accordance with data protection procedures. The clinic serves an urban multiethnic population of approximately 210 000 children, predominantly the London boroughs of Camden, Islington, Greenwich and Haringey.
Social care, police and healthcare providers referred CYP presenting with symptoms raising suspicion of CSA as well as historic allegations of CSA beyond the forensic timescale for acute assault (box 1), ranging from 1 week to 1 year after the episode. Some CYP were referred for review after their initial presentation to the separate sexual assault referral centre (for acute assaults), which did not provide follow-up for prepubertal children. The referrers were asked to provide details of referral reason, strategy meetings/conferences, achieving best evidence interview and social care chronology.
Clinic format
The clinic, led by a consultant paediatrician with a special interest in child abuse (DH), is based in the Children's Outpatients Department. Paediatric consultants and supervised trainee paediatricians with level 3 or above child protection training,21 paediatric nurses and a play specialist attend. Opinions from paediatric gynaecology, genitourinary medicine and the child and adolescent mental health service (CAMHS) are available.
On arrival, the consultant paediatrician and play specialist introduce themselves to the CYP, and accompanying adults (figure 1). The play specialist uses appropriate play and discussion to prepare the CYP, while the history is taken, with the social worker where appropriate; older children may be seen alone. Consent is obtained for photodocumentation. There is discussion regarding testing for sexually transmissible infection (STI) and samples are sent with a laboratory chain of evidence form.22 Discussion of findings includes reassurance to the child about his/her health. They are encouraged to ask questions either alone or in the presence of a trusted carer. Further discussion includes information on sexual abuse and keeping safe; management plan; follow-up and referrals. The multiagency team and parents, where appropriate, receive copies of the written report. Abnormal findings supportive of CSA (as defined by RCPCH16) are subsequently independently peer-reviewed.23 Contemporaneous documentation of the history and examination are recorded on a standardised clinical proforma (available on request) with relevant information from the play specialist.
Pathway of the child through the dedicated historic child sexual abuse assessment clinic. †Child seen alone if appropriate; STI, sexually transmitted infection.
Analysis
Prospectively extracted data included demographics, source and indication for referral and examination findings, which were entered into a secure Microsoft Excel Database. Data regarding other maltreatment were not included in this analysis. Data on clinical findings of the paediatric assessment, including unmet health concerns, were collected retrospectively from the medical records and entered into the same database. R V.3.03 software was used for analyses; statistical significance was defined as p<0.05 (Team RC. R: a language and environment for statistical computing. 2014). The t-test was used to compare variation in reasons for referral according to age. Association between physical findings supportive of CSA and reasons for referral were tested using Fisher's exact test.
Results
During the study period, 249 children (80% girls) with an allegation or suspicion of historic sexual abuse were assessed in the clinic. Overall, 207 children (83%) were aged <13 years (range 1–17 completed years). Median age was 7 years (SD 4.3). The caregiver reported a disability in 36 (14.5%) children, including Down syndrome, learning difficulty, speech delay, autism or attention deficit hyperactivity disorder.
Indication for referral varied significantly with age (p<0.001). Younger children tended to present with physical and behavioural symptoms triggering suspicion of CSA. Allegations of penetration occurred in 79 (31.5%) of all CYP, increasing from 16% in those under 5 years, to 71% among aged 13–17 years (figure 2). Average age was significantly higher among children presenting with allegations of penetration compared with all other reasons for referral (mean age 10.1 vs 6.2 years, t=6.96, p<0.001).
Indications for referral to the dedicated historic child sexual abuse assessment clinic according to age. †Multiple concerns included any combination of the other indications for referral to the clinic: alleged penetration, alleged touching, physical or behavioural symptom, sexual abuse in a sibling and/or another person making an allegation regarding the child. Source of referrals (n(%)): social care 140 (56.5), community paediatrician 32 (13), hospital paediatrician 29 (11.7), primary care provider 22 (8.9), police 18 (7.3), others including school nurses, specialist nurse and undocumented source 8 (3.2).
Figure 3 shows six categories of clinical findings from the paediatric assessment, distributed across age groups; some children had more than one finding within each category (table 1). Among the 249 children, there were unmet medical concerns related to the allegation or suspicion of CSA in 141 (57%) children, including the need for STI screening, or vulvovaginitis in children referred with itching or vaginal discharge. In 78 (31%) children, there was an unmet medical concern(s) unrelated to the allegation of CSA detected during the paediatric assessment, for example, lack of immunisations or septate hymen. Anogenital findings supportive of CSA were found in 18 (7%) children. There was an extremely significant association between alleged penetration and findings supportive of CSA (Fisher's exact test, p<0.001). Colposcopic examination was not done in seven (3%) CYP who refused, and nine (3.5%) who had a prior examination.
Detailed description of clinical findings of the paediatric assessment according to age group in 249 children who attended the dedicated historic CSA assessment clinic, London, UK
Clinical findings of the paediatric assessment according to age group in 249 children who attended the dedicated historic child sexual abuse assessment clinic.
A total of 398 individual clinical findings were identified among the 249 children (table 1), ranging from one to eight findings per child, with 45% children having two or more. In total, 75 (30%) children required clinic follow-up. Others were referred for further assessment: 31 (12%) for psychological support to the CAMHS service, and 6 (2%) to medical specialties unrelated to CSA.
Additional findings relevant to the multiagency team
Medical and play specialist teams both identified significant additional information during the paediatric assessment, including new disclosures to the play specialist. There were specific recommendations to social care in 26/249 (10%) cases, concerning contact with family members, housing or placement and further family support. In seven cases where there was very high index of suspicion of CSA, recommendations included assessment of sibling(s) not previously assessed. In six cases, information disclosed by the child and/or parent led to a recommendation to the police to acquire further evidence such as hair samples for drug testing, bedding and police photography. In 15 (6%) cases, the child's parent/caregiver exhibited a high level of anxiety, warranting further psychological assessment.
Discussion
This large study of children attending a specialised clinic in London, UK, with suspicion or allegations of historic CSA, has identified a broad range of unmet health and developmental needs, and important details requiring social care action. Despite the last episode of alleged CSA being up to 1 year earlier, 7% had physical signs supportive of CSA, while a further 57% had a medical concern(s) related to the reason for referral, 31% had an unrelated medical concern(s) and 22% had emotional or behavioural concerns. All of this highlights the value of thorough paediatric history and full examination. Furthermore in 22%, there was specific information relevant to social care and/or police investigations, and identification of carers requiring psychological help. Our findings highlight the benefits of paediatric referral even when the CYP presents outside the ‘forensic timescale’.
Unmet medical concerns, related and unrelated to the alleged abuse, were present at all ages. Common problems in the younger children that contributed to initial suspicion of CSA in the absence of an allegation included genitourinary symptoms, behavioural and developmental concerns. Sexualised behaviour, a common finding in younger children, is not necessarily indicative of CSA and a holistic paediatric assessment aids the differential diagnosis that includes a medical explanation or normal behaviour pattern.24–26 Older children were more likely to make an allegation and require STI screening, pregnancy testing, the identification of psychological symptoms and vulnerability to sexual exploitation.
Previous literature found associations between poor dentition, undernutrition, obesity and underimmunisation with child maltreatment, but few studies focused on the health needs of sexually abused children.27 ,28 Girardet et al20 reviewed all cases of CSA presenting to a tertiary referral centre, noting that 26% of children had a medical or psychological diagnosis warranting intervention. In common with our data, those with medical diagnoses outnumbered the 9% with supportive physical or laboratory evidence of CSA. Although the patient sample was comparable to ours, the study was conducted in the USA, where the patient demographics and structure of healthcare and social support differs. Kirk et al9 from Edinburgh, UK, reviewed medical assessments for children referred with concerns of maltreatment, and found a greater burden of health needs in those presenting with sexual abuse, compared with physical abuse. Although their CSA sample size (267 cases) was similar, and they also identified a high proportion with unmet medical needs (47%), their study encompassed all child protection referrals, rather than solely historic CSA. There was no age stratification or details of the specific health problems found.
Disability, including learning difficulty was present in 14.5% of CYP in our study, comparable to findings of the UK survivor's survey, where 106/756 (14%) victims of CSA identified themselves as having a disability.1 The literature highlights that disabled children are at significantly greater risk of abuse, being 3.1 times more likely to be sexually abused.29–32 Such children can be difficult to engage and examine, thus requiring paediatric expertise and the skill of the play specialist.
Benefits of the social worker's presence at the consultation include hearing first hand the voice of the child and information concerning social issues. A familiar social worker can provide later support, with the knowledge and understanding of the health aspects of the CYP's sexual abuse.
The composition and process of the clinic was informed by the Sexual Assault Referral Centres, UK; the CSA service developed by Hobbs, UK33 and the ‘child advocacy centres’ employed in the USA.34 While models vary, in our setting the police interview had often been undertaken previously off site, allowing freedom to ask direct questions in relation to the CYP's medical history. In the forensic setting, the management of the acute presentation and gathering of forensic evidence is prioritised, and there may not be the time, facilities or expertise to adequately address wider medical, dental and social/emotional needs.
This study is limited as it is a descriptive analysis of a specific clinic, with no comparison group; a small population does not allow categorical statements about varying features across different age groups. The selection criteria used to refer were unknown, and we lack details of comparable prevalence of unmet health concerns in the local population. Demographic data regarding patient ethnicity were not routinely recorded and are therefore, unavailable. There were no standardised assessments, for example, for post-traumatic stress disorder, rather a reliance on the clinician's individual assessments. Onward referral rates varied due to delay following police investigation or refusal of psychological support, among other reasons.
Future research priorities include using qualitative measures of the acceptability and value of the comprehensive assessment to children, caregivers and professionals, addressing their clinic experience relative to their expectations and anxieties. Likewise, detailed evaluation of the role of the play specialist and potential benefit of standardised screening tools, for example, for emotional problems, suicidality and risk of child sexual exploitation, would be valuable.
From a policy perspective, the piloting of the Barnahus Icelandic model in the UK, that is, a partnership between health, police, including mental health and advocacy based on a purpose built house, is an alternative model. This provides a supportive assessment and a psychologist present at interview, linking closely with the court process. The reported benefits in Iceland include increased perpetrator convictions.35 The child-centred approach used in the clinic described in our study can complement the Barnahus by providing a holistic paediatric assessment of the wide spectrum of potential unmet health needs, in addition to the focus on CSA itself.
Conclusion
These results show that there is considerable value in a comprehensive multidisciplinary paediatric assessment of CYP with suspected or alleged historic sexual abuse in identifying unmet health, developmental and social/emotional needs, and findings of forensic relevance. We advocate a dedicated and appropriately staffed CSA clinic service, for assessment and gathering of information in those aged up to 18 years, to aid social care in protecting CYP and to inform family and criminal court proceedings. The clinic provides a child-friendly setting, with an opportunity to listen to the child and promote preventative measures against further abuse, through starting a ‘keeping safe’ discussion supported by written information.
Acknowledgments
We would like to thank Aishani Kanagasundrem for helping with the data entry (year 4 medical student, University College London), Samuel Leigh for statistical analysis (PhD student, Reading University), Liz Wilkinson and Maggs Potter (Play Specialists, University College London Hospital), Ramesh Pydiah (Medical Photographer), Kirsty Phillips and Renara Begum (Administrative staff, University College London Hospital), and all other clinic staff for their contribution towards this study.
References
Footnotes
Contributors DH conceptualised and designed the study, based on the clinic for which she is the clinical lead, and critically revised the final manuscript. SA acquired and analysed the data and drafted the initial manuscript. KB participated in acquiring data. SB critically revised the manuscript. All authors participated in the revision of the initial and subsequent versions of the manuscript and approved the final manuscript as submitted.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.