LEGISLATION * LEGISLATION

Compulsory reporting changin;

MDs' role in sexual-abuse cases

Cameron Johnston

T he College of Physicians and Surgeons of Ontario has a stern message for doctors who suspect that a child patient may have been a victim of sexual assault. Report your suspicions, says the college, or face action by the college's Discipline

Committee. Reporting the sexual assault of a child, even if it is only suspected, no longer poses the patient-confidentiality-versus-patientprotection dilemma that it once did. In fact, some provinces now have statutes, backed by fines, reprimands and possible loss of privileges, that require doctors to report suspicions about possible sexual assault of a child. Under Ontario's Child and Family Services Act (1984), for example, doctors can be fined up to $1000 for failing to report a suspected case of child sexual

boy whom both had examined. In reprimanding the two, the Ontario college warned that doctors must not "turn a blind eye" to the sexual abuse of children and that "it is incumbent on all physicians to remain current with the law and with the expectations of society." (Under the Criminal Code of Canada, sexual assault now includes exhibitionism, voy-

eurism, touching and fondling, as well as acts where a person in a position of authority, such as a teacher, guardian or babysitter, uses that authority to take advantage of a child between 14 and 16 years of age.) Yet, reporting the sexual assault of a child is not a matter of ethics, says Dr. Harvey Kohn, an obstetrician-gynecologist at Victo-

assault to a Children's Aid Society or similar group. Recently, two physicians were fined $400 each in court, and had their licences suspended for 30 days, after they failed to report the sexual assault of an 18-month-old

C amneron Johnston is a freelance writer living in London, Ont. 1162

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Kohn: not always easy for physicians to deal with sexual assault LE I er MAI 1991

ria Hospital Corporation in London, Ont., and a member of the hospital's Child Sexual Assault Committee. "Many of the people we deal with either can't or won't declare the assault, and we are out to protect them," he said. "In order to protect them the matter has to be reported, so in that respect it's not an ethical issue. Legally you must do it. If you even suspect that abuse has occurred, you must report it." Kohn admitted that it is not always easy for physicians to deal with sexual assault. "It's not part of our formal medical training and because of the legal and psychological issues that are involved, many doctors have found it easier to say that nothing has happened." He also pointed out that medical records are permanent evidence, meaning that doctors can be subpoenaed to testify in court several years after the fact, even though they may not have suspected abuse at the time. In some cases heard recently in Ontario courts, more than 10 years had passed between the time the alleged assault took place and the time charges were laid. Ontario is not the only province to advocate compulsory reporting, and physicians in the rest of Canada who do not face such requirements can expect to see them in the future. "There is nothing wrong with reporting these cases, whether it's abuse of a child, an elderly person or wife abuse," said Dr. Lowell Loewen, deputy registrar of the College of Physicians and Surgeons of Saskatchewan. Loewen added that doctors who report wife abuse are not, strictly speaking, protected by legislation, although he was not aware of any cases in which Saskatchewan doctors have been disciplined for reporting such cases. "I think one should make the attempt to correct the situation and report it," he said. "The MAY 1, 1991

courts and the college have been very good at respecting people who report those incidents. Laws of confidentiality are important, but so are people." On a national level, said EikeB-bacitracin-gramicidinHenner Kluge, PhD, the CMA's polymyxin lidocaine hydrochloride director of ethics and legal affairs, physicians will have to start play- The leading line of topical ing a more "fiduciary role" in the antibiotic preparations BRIEF PRESCRIBING INFORMATION welfare of incompetent patients Indications: Cream: Infection in dermatologic disorders particularly such as children and the elderly. where the lesions are moist or weeping. Prophylactically, against contamination in skin grafts, incisions and other clean "The primary obligation of bacterial lesions. For abrasions, minor cuts and wounds, the cream may preand permit normal healing. Burn Cream: For treatvent infection the physician is to the child or the ment and prevention of infection of minor burns and scalds, and of skin pain. Ointment: For treating local infections due to elderly patient, not to the parent relief organisms and amenable to local treatment; these or guardian who brings the patient susceptible include infected wounds, burns and skin grafts; pyodermas; follicto any of the components. ulitis. Contraindlcations: in," he said. "It will be the obliga- Precautions: For externalHypersensitivity use only. Avoid contact with eyes. If an reaction or irritation occurs, discontinue use and consult tion of the doctor to critically adverse a physician. Dosage: Apply a small quantity 2 to 5 times daily, as May evaluate what is told to him or her required, rub in gently if condition permits. Cream/Ointment: be covered with a dressing or left exposed. Supplied: Cream: Each by the guardian." g contains: polymyxin B sulfate 10,000 units, gramicidin 250 ,ug in a white vanishing cream base, pH of 5.0. Also conAlthough the Ontario Medi- (0.25mg) tains methylparaben. Tubes of 15 and 30g. Store at 15 to 250C. Burn Cream: Each g contains: polymyxin B sulfate 10,000 units, cal Association (OMA) is "gener- gramicidin (0.25mg) and lidocaine hydrochloride 50mg. ally satisfied" with the law as it Tubes of 15250,ug and 30g. Store at 15 to 250C. Ointment: Each g contains: polymyxin B sulfate 10,000 units (equivalent to 1 mg polyexists, John Krauser, its associate myxin standard) and bacitracin 500 units. Tubes of 5,15 and 30g. director of health policy, said Full prescribing information available on request. there are still major areas of con- REFERENCES: 1. IMS Canada: Drug Store and Hospital Purchases, December 1990, 2. Barry M. Topical First Aid. Self Medication: A reference for health cern. One area involves a patient professionals. Clarke C, Ebbs H, Krogh C, ed. Canadian Pharmaceuover age 16 who reports he was tical Association, Ottawa 1988:34-35. 3. Reynolds JEF & Parfitt ed. Martindale: The extra pharmacopoeia. The Pharmaceutical abused as a child; a younger sib- K,Press, London 1989:94- 337. 4. Handbook of Antimicrobial Therapy Let Drugs Ther, The Medical Letter, NY 1988:17 -37. 5. Mupirocin Med ling still at home might be ex- -A new topical antibiotic. Med Lett Drugs Ther, The Medical LetNY 1988:30;55-56. 6. Robertson DB & Mailbach Hi. Dermatoposed to the same abuse, notes ter, logic Pharmacology. Basic and clinical pharmacology. Katzing BG, Krauser. ed. Appleton & Lange, California 1987:764. 7. Harvey SC. Antimicrobial Drugs. Remington's Pharnaceutical Sciences. Gennaro AR, "It's not clear whether the act ed. Mack Publishing Co., Pennsylvania 1985:1201-12. 8. McEvoy ed. AHFS Drug Information 89. American Society of Hospital covers the minor child, or if the GK, Pharmacists Inc., MD, 1989:1474-1925. 9. David SD, Polymyxins, doctor's obligation should be\ only Colutin, Vancomycin and Bacitracin, Antimicrobial- Therapy. Kagan BM ed. WB Saunders Company, Toronto 1980:77 83. 10. Sande to the patient who is over 16. If MA and Mandell GL. Antimicrobial agents. The Pharmacological of Therapeutics, Goodman GA, Goodman LS, Rall TW & Murad Basis the over-16 patient demands that F, ed. Collier Macmillan, Toronto, 1985:1170-1194. 11. Krogh CME, MC and Bisson R, ed. Compendium of pharmaceuticals and the doctor take no action, there Gillis Canadian Pharmaceutical Association, Ottawa, will be a question of whether the specialties. 1989:121 -821. 12. Bharadwaj R, Phadke S, Joshi BN: Bacteriology of bum wound using the quantitative full thickness biopsy tech-' doctor should break his oath of nique. Indian J Med Res 1983;78:337 - 342. 13. Noble WC: Skin Coming of Age. J Med Microbiol 1984;17:1 -12. confidentiality to that patient or if Microbiology: 14. Anderson JD: Fusidic acid: new opportunities with an old antihe should report the incident to biotic. Can Med Assoc J 1980;122;765-69. 15. Shanson DC: Staphylococcus aureus. Hosp Infec protect the minor child who might Antibiotic-resistant 1981;2:11 -36. 16. Reeves DS: The pharnacokinetics of fusidic acid. 1987;20:467 - 476. 17. Campoli-Richards M, Chemother Antimicrob still be at risk." Ward A: Mupirocin: A Review of its AntibacterialActivity, PharmaProperties and Therapeutic Use. Drugs 1986;32:425-444. According to Krauser, the cokinetic 18. Dux PH, Fields L, Pollock D: 2% Topical Mupirocin Versus OMA is "90% there" in terms of Systemic Erythromycin and Cloxacillin in Primary and Secondary Skin Curr Ther Res 1986;40:933-940. 19. Downey D, coming up with an answer, but the Infections. Hadley K, Lever R, Mackie R: Staphlococcal colonization in atopic

Polysporin*

association is awaiting further discussions with Children's Aid societies, Ontario's Ministry of Community and Social Services and the Canadian Medical Protective Association before it issues any guidelines. Dr. John Martin, chairman of

dermatitis and the effect of topical mupirocin therapy Br J Dermatol 1988;119:189-198. 20. Reilly G, Spender R: Pseudonomic acid- a new antibiotic for skin infections. J Antimicrob Chemother 1984;13:295 - 298. 21. Data on file, December 1990, Burroughs Wellcome Inc. *Trademark c Burroughs Wellcome Inc. 1991 POLY-EJ-02/91

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CONSUMER PRODUCTS DIVISION

BURROUGHS WELLCOME INC.

KIRKLANO, OU

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CANADA

IPAABI LE.2ic

the Newfoundland Medical Asso-

ciation's Ethical Affairs CommitCAN MED ASSOC J 1991; 144 (9)

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Program helps abused children deal with courtroom pressures A family court program to help children who have been sexually or physically abused prepare for the ordeal of a courtroom trial has lead to an increase in the number of convictions in cases involving sexual assault against children, a pediatrician in London, Ont., says. Unfortunately, a federalprovincial dispute over who should pay the project's $200 000 annual cost has left the program in limbo since the end of 1990, and has left as many as 100 children without counselling before they enter the courtroom to face alleged molesters. Launched by the London Family Court Clinic in 1988, the Child Witness Program helped more than 200 children, most of whom had been sexually assaulted, prepare to give testimony. Under the program, children were counselled by social workers and psychologists about the court's functions and what each person in the courtroom would be doing. In some cases, children were given the run of an empty courtroom to familiarize themselves with the

setting. Dr. Gary Joubert, a member of the Victoria Hospital Corporation Child Sexual Assault Committee and assistant professor of pediatrics at the University of Western Ontario, told CMAJ the conviction rate tee, said he is not aware of any legislation, present or pending, that would require Newfoundland physicians to report cases of sexual assault. "My concern is that perhaps this kind of legislation can be too detailed. We can't be spelling out to the last iota what the physician 1164

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for sexual-assault cases has risen to 38% since the program's introduction, and it is still rising. "This is the payoff," he said. "The child is stronger and better able to testify and there are more guilty pleas because the perpetrators do not want to face a confident child in court."

In some cases children were given the run of an empty courtroom to familiarize themselves with the setting.

One police officer who handles sexual-assault cases for the London Police Department said he would probably lay fewer charges without the program because unprepared children are easily intimidated by an appearance in court and thus make poor witnesses. Describing the project as should be doing. That should be self-evident. Our medical licensing board tries to hire the best people and we expect that they should know what to do." On a personal level, Martin feels that cases of suspected abuse should be reported to the police. "You have to be sure of your

"a phenomenal success," Michael Greenberg, child-abuse consultant with Family and Children's Services of London, said a major aim of the program was to reduce the stressinduced trauma caused by the adult court system. Through the program, "6children were empowered to give their testimony in adult form. They felt confident about themselves, they were relaxed, and their self-esteem was raised so they felt as if they were being believed." However, Greenberg added, the project was never intended as anything more than a demonstration project for the Department of National Health and Welfare, which provided seed money for the program. "It was only at the 11th hour that we started scrambling to see how we could keep it going because it was a success and it worked well." Greenberg said Ontario's Ministry of Community and Social Services, along with the Attorney General's Office and Health and Welfare Canada, is still looking at ways to revive the program, but major issues will include funding and ad-

ministration. "It would take a lot of work and it would be a real cooperative effort. For now, I have to say the program is hanging in limbo."

facts, and there are going to be cases where you don't have enough evidence, but you are suspicious. In cases like that I think you should gather all the facts you can and hand them over to the police. Let them handle it from there. At least you will have covered your tracks."m LE I er MAI 1 991