The Role of the Paediatric By P.M.
Lafferty,
Surgeon in Alleged Child Sexual Abuse G.M. Lawson,
J.D. Orr, and W.G.
Scobie
Edinburgh, Scotland l TWO hundred ninety cases of alleged child sexual abuse (CSA) were reported in Edinburgh and the Lothian region over the 7-year period from 1982 through 1998. We have found an increase in the incidence of alleged GSA. which has resulted in greater involvement of the paediatric surgeon. CSA was found to be occurring with increasing frequency in younger children. The physical examination and the role of general anaesthesia are discussed together with the data about the collection of forensic material. 0 1990 by W.B. Saunders Company. INDEX WORDS:
Child sexual abuse.
R
ECENT EVIDENCE suggests a dramatic rise in the incidence of alleged child sexual abuse (CSA), both nationally and internationally.’ Increased public and medical awareness of the problem has led to pressure being put on the clinician, to provide evidence in favour or against the likelihood of the allegation. In Edinburgh and the Lothian region, the paediatric surgeon has been incorporated into the primary management team in all cases of alleged CSA. Thus, a unique appraisal of the value of physical examination, and the role of the paediatric surgeon in alleged CSA was possible. MATERIALS
AND
METHODS
Hospital Records at the Western General Hospital Paediatric Surgical Unit were reviewed, together with all cases of assault reported to the police surgeon in Edinburgh and the Lothian region from 1982 to 1988, inclusive. It must be emphasised, that although all available records of reported assault were reviewed, they do not necessarily reflect the actual figures. All cases of alleged CSA up to, but excluding, children of 16 years of age, were included. From 1984, Lothian Health Board policy regarding CSA included paediatric surgeons as members of the primary management staff. Arrangements for examination were coordinated by the police surgeon, who contacted one of the specialist attendant teams, eg, paediatric surgeon, obstetrician and gynaecologist, general practitioner, paediatrician, or genitourinary physician. Children with evidence of abnormal physical findings suggestive of sexual abuse were designated the “positive findings” group. The categories of positive findings are based on official collaborative
reports of the police surgeon and attendant specialist (Fig 1). If a conclusion was drawn from the examination it was categorised into the following three groups: (1) definite evidence of CSA; (2) no evidence of CSA; (3) possible CSA. RESULTS
Incidence, Age, and Sex
Over the 7-year review period, there has been a rise in the number of cases of alleged CSA reported to the police surgeon (Fig 2). Twenty-six cases were seen at the Western General Hospital Paediatric Surgical Unit from 1986 to 1988; 18 cases (69%) were seen in 1988. The mean age at presentation was 13.75 years (range, 11 to 15 years) in 1982, and 9.21 years (range, 1 to 15 years) in 1988. A mode age of 15 years was seen throughout the series. However, from 1986, there was a marked increase in 3- and 4-year-old patients. By 1988, 32% of all children seen were in the 3 to 5 year age group (Fig 3). The mean ages of patients seen by the police surgeon and the paediatric surgeon was 6.5 years (range, 2 to 14 years), compared with those seen by the police surgeon alone (mean age, 10.6 years; range, 2 to 15 years), and those seen by both the police surgeon and the obstetrician-gynaecologist (mean age, 13.1 years; range, 3 to 15 years). Thirty-six (12%) boys and 254 (87%) girls were examined. The paediatric surgeon was involved in the examination of 52 (18%) patients, all but one of whom were girls. In the last 3 years of the series, the paediatric surgeon has been the joint attendant examiner in 2.3%, 26%, and 35% of cases, respectively. This is reflected in the location of the physical examination (Fig 4). The Examination
From the Department of Paediatric Surgery, Western General Hospiral, Edinburgh, Scotland. Presented at the 36th Annual Congress of the British Association of Paediatric Surgeons, Nottingham, England, July 19-21, 1989. Address reprint requests to P.M. Lafferty. FRCS. Paediatric Surgical Department, Western General Hospital, Crewe Rd. Edinburgh, EH4 2XlJ. Scotland. o 1990 by W.B. Saunders Company. 0022-3468/90/2504-0014%03.00/0
Two hundred ninety children were examined for signs of sexual abuse. Two hundred sixty-five (91%) were examined without anaesthesia, 30 (10%) received general anaesthesia, and five (1.7%) had examinations both with and without general anaesthesia. One hundred sixty-three (56%) children showed documented evidence of abnormal physical findings (positive group); 126 (43%) children had no evidence of abnormal physical signs (negative group). Only 25% of the boys examined showed abnormal findings, despite 79% of the boys having histories strongly suggestive of physical sexual abuse. Sixty
434
Journalof
Pediatric
Surgery,
Vol
25,
No
4
(April), 1990: pp 434-437
435
PAEDIATRIC SURGEON & CHILD SEXUAL ABUSE
@
ANUS
No.of A cases \ @
@
@
@
PERINEUM VULVA INTROITUS
1817-
\
LABIA
HYMEN
16-
:” a. b. c. d. e.
Signs olextemel mum (Inc. tsarsand scars) Inflammationkfylhema Evldenc, of dilation or ~f~ation Dlschargn (all) Foreign body
141312lllo98-
VAGlNA’
76-
Categories of positive findings.
Fig 1.
15-
5-
percent of the girls examined showed abnormal findings related to alleged CSA. Of those children examined under general anaesthesia, 18 (60%) had positive findings, 12 (40%) had none; all such examinations were conducted with a paediatric surgeon as principal examiner. No other specialist group (wide infra) incorporated general anaesthesia in their examination. No comments were made regarding abnormalities of the vagina despite the additional access afforded by general anaesthesia. All other positive findings in this group would have been detected at the time of external examination. No additional information was obtained, nor additional forensic material collected, in the five children who underwent examination both with and without anaesthesia. Conclusions regarding the likelihood of sexual abuse, based on physical examination (wide supra), were drawn in 16 (53%) of the children undergoing examina110-
432lOAge in years Fig 3.
Age distribution of 1988 cases.
tion with general anaesthesia, compared with 98 (36%) of the children undergoing examination without general anaesthesia. In both groups, the majority conclusion reached was that there was no evidence of CSA. General anaesthesia facilitated both instrumentation and the intrusiveness of examination, allowing for proportionately more forensic material to be collected. However, this did not result in a significant increase in the number of positive findings. The most commonly described genital abnormality was perineal, vulval, or introital inflammation (18%) (Table 1). The most common physical sign in those
loo90-
m70 -
Number of cases
60. SO40302%
e
10-
‘.... . ../ ‘..* ,_..-..
n
ObsiGynae
”
1992
1983
1984
1985
1986
1987
1998
Fig 2. Numbers of oases of alleged CSA in the Edinburgh and Lothisn district, from IS82 through 1988.
0
7 1982
1983
Fig 4.
1984
1985
1986
1987
Location of examination.
-1988
436
LAFFERTY ET AL Table 1. Most Commonly Described
Positive Findings
1. Perineal/vulval/introital inflammation/erythema
18%
2. Hymenal appearance relating to dilatation or perforation
13%
3. External signs of trauma to the hymen (tears and scars)
12%
4. Vaginal discharge (ALL)
11%
5. Vaginal inflammation/erythema
8%
6. Labial inflammation/erythema
7%
considered to have been sexually abused was trauma to the hymen. Examination Specificity and Conclusions
Police surgeons were involved in all examinations for CSA during the review period. Since 1983, additional attendant specialists have included obstetricians and gynaecologists, paediatricians, general practitioners, genitourinary physicians, and paediatric surgeons. Despite this, the number of examinations positive for CSA per year has remained within a range of 52% to 65%. The overall conclusion rate has declined from 57% in 1984 to 26% in 1988. Analysis of the three main attending specialists showed that the police surgeon and the paediatric surgeon made conclusions in 57% of cases, whereas the police surgeon alone, and the police surgeon and the obstetric-gynaecologist made conclusions in 32% and 36% of the cases, respectively. An attempt was made to correlate the child’s personality with conclusion rates. The child’s personality was assessed in 235 (81%) cases and categorised into four main groups: (1) bright and cooperative (61%); depressed and withdrawn (12%); (3) crying and agitated (15%); and (4) educationally subnormal or immature for chronological age (10%). The group of the depressed and withdrawn child correlated best with a proportionately high conclusion rate (60%) one third of these being positive, ie, definite evidence of CSA. DlSCUSSlON An increase in the incidence of alleged CSA during the review period has been reported. The preponderance of girl patients has confirmed both the subjective nature and subjective interpretation of the physical findings, and has reaffirmed the lack of normative data on prepubertal female anatomy. Boy patients generally show far fewer signs of sexual abuse, even in the presence of highly suggestive histories, which should be relied on more in both sexes. A second, younger, peak age for alleged CSA has arisen in the 7 years studied, accounting for the introduction of the paediatric surgeon, whose contributions have included a higher overall conclusion rate, compared with the two other main specialist attendants. This has been at the expense of the frequent use
of general anaesthesia. General anaesthesia allowed both for more forensic material to be collected, and for a more intrusive examination; however, no more relevant information was obtained. We concur in this respect with the independent second opinion panel,2 following the Cleveland Inquiry, that the level of intrusiveness of the examination should match the level of suspicion. Accordingly, general anaesthesia is no longer used routinely in the Western General Hospital Paediatric Surgical Unit. By 1988, 109 cases of alleged CSA were seen by five different attendant specialists in five different locations. This represents a need for more clearly defined guidelines, and a convergence of thought regarding the management of CSA. Hopefully, the trend away from police examination rooms and gynaecological units heralds such a change. The labeling of physical signs as abnormal is a subjective analysis in the absence of normal parameters. Hence, physical examination, in the majority of cases, can only be regarded as an aid toward a final diagnosis. Levitt,3 Herman-Giddens and Frothingham, and the DHSS’ guidelines all emphasise the secondary role of examination, compared with a detailed and meticulously taken history. General anaesthesia has only a minor part to play in the management of CSA. There are few, if any, indications for examination both with and without anaesthesia because little additional information is collected under these circumstances. Notably absent from the positive findings group were comments regarding actual hymenal diameter, anal tone, or reflex anal dilatation. This reflects the gross difficulty experienced in interpretation of such findings in this series and those of others (Clayden, Roberts,’ and Stanton and Sutherland’). Digital and proctoscopic examination of the anus was largely unhelpful, in either sex, in elucidating positive physical signs of abuse. Only 17 cases had reference made to abnormal anal findings. These included mild erythema in the majority of cases. The role of the paediatric surgeon to date has been to provide expertise regarding normal female genital anatomy and anaesthetic liaison if required. However, the paediatric surgeon may not be regarded as expert in the absence of normative data. Their future role must include an attempt at assessing the range of normal in the prepubertal genitalia. ACKNOWLEDGMENT The authors wish to thank DMJ Path, Regis Professor Regional Procurator Fiscal, paper and for allowing access
Professor A. Busuttil, MD, FRC Path, of Forensic Medicine, and J.D. Lowe, for their assistance in preparing this to case records.
437
PAEDIATRIC SURGEON & CHILD SEXUAL ABUSE
REFERENCES 1. HobbsCJ, Wynne JM: Management of sexual abuse. Arch Dis Child 62:1182-l 187, 1987 2. Independent Second Opinion Panel, Northern Regional Health Authority (October 1987): Child sexual abuse: Principles of good practice. Br J Hosp Med 39:54-62, 1988 3. Levitt CJ: Sexual abuse in children-A compassionate yet thorough approach to evaluation. Post Grad Med 80:201-215, 1986 4. Herman-Giddens ME, Frothingham TE: Prepubertal female genitalia: Examination for evidence of sexual abuse. Pediatrics 80:203-208,1987
5. DHSS Standing Medical Advisory Committee: Diagnosis of Child Sexual Abuse: Guidelines for Doctors. London, England, HMSO, 1988 6. Clayden G: Anal appearances and child sex abuse. Lancet 1:620, 1987 7. Roberts R: Sexual abuse of children in Leeds. Br Med J 292:1527,1986 8. Stanton A, Sutherland R: Prevalance of reflex anal dilatation in 200 children. Br Med J 298:802-803, 1989
Lafferty,
Surgeon in Alleged Child Sexual Abuse G.M. Lawson,
J.D. Orr, and W.G.
Scobie
Edinburgh, Scotland l TWO hundred ninety cases of alleged child sexual abuse (CSA) were reported in Edinburgh and the Lothian region over the 7-year period from 1982 through 1998. We have found an increase in the incidence of alleged GSA. which has resulted in greater involvement of the paediatric surgeon. CSA was found to be occurring with increasing frequency in younger children. The physical examination and the role of general anaesthesia are discussed together with the data about the collection of forensic material. 0 1990 by W.B. Saunders Company. INDEX WORDS:
Child sexual abuse.
R
ECENT EVIDENCE suggests a dramatic rise in the incidence of alleged child sexual abuse (CSA), both nationally and internationally.’ Increased public and medical awareness of the problem has led to pressure being put on the clinician, to provide evidence in favour or against the likelihood of the allegation. In Edinburgh and the Lothian region, the paediatric surgeon has been incorporated into the primary management team in all cases of alleged CSA. Thus, a unique appraisal of the value of physical examination, and the role of the paediatric surgeon in alleged CSA was possible. MATERIALS
AND
METHODS
Hospital Records at the Western General Hospital Paediatric Surgical Unit were reviewed, together with all cases of assault reported to the police surgeon in Edinburgh and the Lothian region from 1982 to 1988, inclusive. It must be emphasised, that although all available records of reported assault were reviewed, they do not necessarily reflect the actual figures. All cases of alleged CSA up to, but excluding, children of 16 years of age, were included. From 1984, Lothian Health Board policy regarding CSA included paediatric surgeons as members of the primary management staff. Arrangements for examination were coordinated by the police surgeon, who contacted one of the specialist attendant teams, eg, paediatric surgeon, obstetrician and gynaecologist, general practitioner, paediatrician, or genitourinary physician. Children with evidence of abnormal physical findings suggestive of sexual abuse were designated the “positive findings” group. The categories of positive findings are based on official collaborative
reports of the police surgeon and attendant specialist (Fig 1). If a conclusion was drawn from the examination it was categorised into the following three groups: (1) definite evidence of CSA; (2) no evidence of CSA; (3) possible CSA. RESULTS
Incidence, Age, and Sex
Over the 7-year review period, there has been a rise in the number of cases of alleged CSA reported to the police surgeon (Fig 2). Twenty-six cases were seen at the Western General Hospital Paediatric Surgical Unit from 1986 to 1988; 18 cases (69%) were seen in 1988. The mean age at presentation was 13.75 years (range, 11 to 15 years) in 1982, and 9.21 years (range, 1 to 15 years) in 1988. A mode age of 15 years was seen throughout the series. However, from 1986, there was a marked increase in 3- and 4-year-old patients. By 1988, 32% of all children seen were in the 3 to 5 year age group (Fig 3). The mean ages of patients seen by the police surgeon and the paediatric surgeon was 6.5 years (range, 2 to 14 years), compared with those seen by the police surgeon alone (mean age, 10.6 years; range, 2 to 15 years), and those seen by both the police surgeon and the obstetrician-gynaecologist (mean age, 13.1 years; range, 3 to 15 years). Thirty-six (12%) boys and 254 (87%) girls were examined. The paediatric surgeon was involved in the examination of 52 (18%) patients, all but one of whom were girls. In the last 3 years of the series, the paediatric surgeon has been the joint attendant examiner in 2.3%, 26%, and 35% of cases, respectively. This is reflected in the location of the physical examination (Fig 4). The Examination
From the Department of Paediatric Surgery, Western General Hospiral, Edinburgh, Scotland. Presented at the 36th Annual Congress of the British Association of Paediatric Surgeons, Nottingham, England, July 19-21, 1989. Address reprint requests to P.M. Lafferty. FRCS. Paediatric Surgical Department, Western General Hospital, Crewe Rd. Edinburgh, EH4 2XlJ. Scotland. o 1990 by W.B. Saunders Company. 0022-3468/90/2504-0014%03.00/0
Two hundred ninety children were examined for signs of sexual abuse. Two hundred sixty-five (91%) were examined without anaesthesia, 30 (10%) received general anaesthesia, and five (1.7%) had examinations both with and without general anaesthesia. One hundred sixty-three (56%) children showed documented evidence of abnormal physical findings (positive group); 126 (43%) children had no evidence of abnormal physical signs (negative group). Only 25% of the boys examined showed abnormal findings, despite 79% of the boys having histories strongly suggestive of physical sexual abuse. Sixty
434
Journalof
Pediatric
Surgery,
Vol
25,
No
4
(April), 1990: pp 434-437
435
PAEDIATRIC SURGEON & CHILD SEXUAL ABUSE
@
ANUS
No.of A cases \ @
@
@
@
PERINEUM VULVA INTROITUS
1817-
\
LABIA
HYMEN
16-
:” a. b. c. d. e.
Signs olextemel mum (Inc. tsarsand scars) Inflammationkfylhema Evldenc, of dilation or ~f~ation Dlschargn (all) Foreign body
141312lllo98-
VAGlNA’
76-
Categories of positive findings.
Fig 1.
15-
5-
percent of the girls examined showed abnormal findings related to alleged CSA. Of those children examined under general anaesthesia, 18 (60%) had positive findings, 12 (40%) had none; all such examinations were conducted with a paediatric surgeon as principal examiner. No other specialist group (wide infra) incorporated general anaesthesia in their examination. No comments were made regarding abnormalities of the vagina despite the additional access afforded by general anaesthesia. All other positive findings in this group would have been detected at the time of external examination. No additional information was obtained, nor additional forensic material collected, in the five children who underwent examination both with and without anaesthesia. Conclusions regarding the likelihood of sexual abuse, based on physical examination (wide supra), were drawn in 16 (53%) of the children undergoing examina110-
432lOAge in years Fig 3.
Age distribution of 1988 cases.
tion with general anaesthesia, compared with 98 (36%) of the children undergoing examination without general anaesthesia. In both groups, the majority conclusion reached was that there was no evidence of CSA. General anaesthesia facilitated both instrumentation and the intrusiveness of examination, allowing for proportionately more forensic material to be collected. However, this did not result in a significant increase in the number of positive findings. The most commonly described genital abnormality was perineal, vulval, or introital inflammation (18%) (Table 1). The most common physical sign in those
loo90-
m70 -
Number of cases
60. SO40302%
e
10-
‘.... . ../ ‘..* ,_..-..
n
ObsiGynae
”
1992
1983
1984
1985
1986
1987
1998
Fig 2. Numbers of oases of alleged CSA in the Edinburgh and Lothisn district, from IS82 through 1988.
0
7 1982
1983
Fig 4.
1984
1985
1986
1987
Location of examination.
-1988
436
LAFFERTY ET AL Table 1. Most Commonly Described
Positive Findings
1. Perineal/vulval/introital inflammation/erythema
18%
2. Hymenal appearance relating to dilatation or perforation
13%
3. External signs of trauma to the hymen (tears and scars)
12%
4. Vaginal discharge (ALL)
11%
5. Vaginal inflammation/erythema
8%
6. Labial inflammation/erythema
7%
considered to have been sexually abused was trauma to the hymen. Examination Specificity and Conclusions
Police surgeons were involved in all examinations for CSA during the review period. Since 1983, additional attendant specialists have included obstetricians and gynaecologists, paediatricians, general practitioners, genitourinary physicians, and paediatric surgeons. Despite this, the number of examinations positive for CSA per year has remained within a range of 52% to 65%. The overall conclusion rate has declined from 57% in 1984 to 26% in 1988. Analysis of the three main attending specialists showed that the police surgeon and the paediatric surgeon made conclusions in 57% of cases, whereas the police surgeon alone, and the police surgeon and the obstetric-gynaecologist made conclusions in 32% and 36% of the cases, respectively. An attempt was made to correlate the child’s personality with conclusion rates. The child’s personality was assessed in 235 (81%) cases and categorised into four main groups: (1) bright and cooperative (61%); depressed and withdrawn (12%); (3) crying and agitated (15%); and (4) educationally subnormal or immature for chronological age (10%). The group of the depressed and withdrawn child correlated best with a proportionately high conclusion rate (60%) one third of these being positive, ie, definite evidence of CSA. DlSCUSSlON An increase in the incidence of alleged CSA during the review period has been reported. The preponderance of girl patients has confirmed both the subjective nature and subjective interpretation of the physical findings, and has reaffirmed the lack of normative data on prepubertal female anatomy. Boy patients generally show far fewer signs of sexual abuse, even in the presence of highly suggestive histories, which should be relied on more in both sexes. A second, younger, peak age for alleged CSA has arisen in the 7 years studied, accounting for the introduction of the paediatric surgeon, whose contributions have included a higher overall conclusion rate, compared with the two other main specialist attendants. This has been at the expense of the frequent use
of general anaesthesia. General anaesthesia allowed both for more forensic material to be collected, and for a more intrusive examination; however, no more relevant information was obtained. We concur in this respect with the independent second opinion panel,2 following the Cleveland Inquiry, that the level of intrusiveness of the examination should match the level of suspicion. Accordingly, general anaesthesia is no longer used routinely in the Western General Hospital Paediatric Surgical Unit. By 1988, 109 cases of alleged CSA were seen by five different attendant specialists in five different locations. This represents a need for more clearly defined guidelines, and a convergence of thought regarding the management of CSA. Hopefully, the trend away from police examination rooms and gynaecological units heralds such a change. The labeling of physical signs as abnormal is a subjective analysis in the absence of normal parameters. Hence, physical examination, in the majority of cases, can only be regarded as an aid toward a final diagnosis. Levitt,3 Herman-Giddens and Frothingham, and the DHSS’ guidelines all emphasise the secondary role of examination, compared with a detailed and meticulously taken history. General anaesthesia has only a minor part to play in the management of CSA. There are few, if any, indications for examination both with and without anaesthesia because little additional information is collected under these circumstances. Notably absent from the positive findings group were comments regarding actual hymenal diameter, anal tone, or reflex anal dilatation. This reflects the gross difficulty experienced in interpretation of such findings in this series and those of others (Clayden, Roberts,’ and Stanton and Sutherland’). Digital and proctoscopic examination of the anus was largely unhelpful, in either sex, in elucidating positive physical signs of abuse. Only 17 cases had reference made to abnormal anal findings. These included mild erythema in the majority of cases. The role of the paediatric surgeon to date has been to provide expertise regarding normal female genital anatomy and anaesthetic liaison if required. However, the paediatric surgeon may not be regarded as expert in the absence of normative data. Their future role must include an attempt at assessing the range of normal in the prepubertal genitalia. ACKNOWLEDGMENT The authors wish to thank DMJ Path, Regis Professor Regional Procurator Fiscal, paper and for allowing access
Professor A. Busuttil, MD, FRC Path, of Forensic Medicine, and J.D. Lowe, for their assistance in preparing this to case records.
437
PAEDIATRIC SURGEON & CHILD SEXUAL ABUSE
REFERENCES 1. HobbsCJ, Wynne JM: Management of sexual abuse. Arch Dis Child 62:1182-l 187, 1987 2. Independent Second Opinion Panel, Northern Regional Health Authority (October 1987): Child sexual abuse: Principles of good practice. Br J Hosp Med 39:54-62, 1988 3. Levitt CJ: Sexual abuse in children-A compassionate yet thorough approach to evaluation. Post Grad Med 80:201-215, 1986 4. Herman-Giddens ME, Frothingham TE: Prepubertal female genitalia: Examination for evidence of sexual abuse. Pediatrics 80:203-208,1987
5. DHSS Standing Medical Advisory Committee: Diagnosis of Child Sexual Abuse: Guidelines for Doctors. London, England, HMSO, 1988 6. Clayden G: Anal appearances and child sex abuse. Lancet 1:620, 1987 7. Roberts R: Sexual abuse of children in Leeds. Br Med J 292:1527,1986 8. Stanton A, Sutherland R: Prevalance of reflex anal dilatation in 200 children. Br Med J 298:802-803, 1989
