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Taking action on suspected child sex abuse

Sexual abuse of children and young people is an important cause of ill health in

the UK today. The short-term effects may involve not just the physical health but also the psychological, social and educational functioning of the child, while the

long-term effects can be intermittent, continuous, situational, sporadic or

life-long, and are not just physical but also social and emotional.

Safeguarding children and promoting their welfare requires a multi-agency approach in which we have to work closely with other professionals belonging to other disciplines, including education, social services and the police.

Working with other agencies presents special challenges in dealing with a sexually active young person, where we have to play our part in detecting and preventing abuse and neglect, while providing a confidential health service.

Most sexual abuse is unrecognised and hidden. Bringing the problem out into the open, reducing its frequency and impact, and seeking timely help for victims will depend on widespread change in attitude to sexual abuse.

What are the effects of child sexual abuse?

The short-term effects on the child include behaviour problems, education and learning problems, anxiety, depression and withdrawal, while the long-term effects on the adult include mental health problems, somatisation, sexual adjustment problems, delinquency, acts of violence, difficulty in forming relationships and problems in parenting their own children.

There is no simple, one-to-one relationship between the severity of the abuse and its impact. The consequences will depend on the severity and duration of the abuse, its associated features (for example, deprivation) and the child itself (some are more resilient than others).

Perpetrators may go to great lengths to make sure their victims remain silent. Victims are made to feel helpless and may blame themselves. The NSPCC's Child Maltreatment study estimated that less than a quarter of abused patients tell someone at the time, a third speak about it some time later, and the rest never

tell anyone.1

What is the incidence

and prevalence?

We do not know the true incidence of sexual abuse in children and young people. It is estimated that three-quarters of GPs will see at least one case of sexual abuse every two years. Sexual abuse is one-and-a half to three times more common in females than males.1 Prevalence studies tell us that sexual abuse of children and young people is actually much more common than this. One of the issues in describing the prevalence of sexual abuse depends on how it is defined.

The clearest picture we have to date of prevalence in the UK is the NSPCC study Child Maltreatment.2 In this study, the researchers classified sexual experiences as abusive if: ‘The perpetrator was a parent or caregiver or it occurred against respondent's wishes, or it was a ‘‘consensual'' act but occurred when the respondent was under 12 and the perpetrator was five or more years older'.

This study found that, contrary to stereotype, sexual abuse by a parent was relatively rare: domestic sexual abuse most commonly involved a brother or stepbrother, but the most frequent perpetrator was an unrelated but known person.

What is the GP's role in suspected abuse?

Dealing with any form of child abuse is challenging for GPs, and regular and up-to-date education is essential. Knowing what to do and where to find information and advice will help you act in a timely and appropriate way and help keep children safe.3,4 See the box on the RCGP's advice.

As GPs we have an important part to play, but will only be able to play that part if we are able to acknowledge the problem and be knowledgeable about what to look for and how to act.

GPs should generally have a low threshold for seeking help and advice from colleagues with expertise in child protection, such as named or designated professionals. We have a particularly important part to play in the detection, prevention and continuing management of all forms of abuse.2 This article looks at the recognition of sexual abuse in children and young people as it may present to the GP, where to obtain advice and how to make a referral.

Sexual abuse is a difficult problem; by nature it tends to be hidden, and the signs and symptoms are difficult to interpret. It is also a disturbing topic and it can be tempting to ignore the signs and symptoms. Sexual abuse also often coexists with other forms of abuse (physical or emotional) or with neglect, so the picture can be confusing.

When thinking about the problem, it is helpful to remember that sexual abuse of a child by a parent is relatively rare.2 Any child of whatever age can suffer sexual abuse, but it is commonly suffered when a child reaches adolescence, and the perpetrator is often someone known to but unrelated to the victim.2 The victim is unlikely to tell anyone what has happened.

In general practice, we are more likely to see the survivors of abuse than recent victims. Survivors consult their GP very frequently. They have high levels of morbidity: as well as greater psychological ill health, they are also far more likely to be investigated or have surgical treatment (and often with negative findings) for physical problems.5

What constitutes child sexual abuse and when should be GP be concerned?

According to The Working Together to Safeguard Children 2006 document, ‘Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, including prostitution, whether or not the child is aware of what is happening. The activities may involve physical contact, including penetrative, that is rape, buggery or oral sex, or

non-penetrative acts. They may include non-contact activities, such as involving children in looking at, or in the production of, pornographic material or watching sexual activities, or encouraging children to behave in sexually inappropriate ways'.6

In practice, however deciding when to be suspicious can be difficult: if you consider the the example scenarios in the box ‘Is this abuse', in many of the situations described you will probably conclude that the answer depends on other factors.

However, we often do not have enough information to decide. This is why talking to other members of your practice (such as other GPs or the health visitor or school nurse) and obtaining advice from experts (such as the named or designated doctor or nurse for child protection) can help.

How can the

GP recognise possible abuse?

There are many barriers to recognising sexual abuse. It is an emotional issue for the doctor, and it may seem easier to delay dealing with the issue or even deny the evidence. It is a problem that will be hidden by both the perpetrator and the victim, and it is also intrinsically difficult to diagnose. Abuse may continue for many years before there are any obvious signs.

Suspecting a family member is exceptionally hard for GPs. The relationship between a GP and patient relies on trust, and the doctor-patient relationship, while not actually one of friendship, has the ‘moral texture' of friendship. This is particularly difficult when working with child abuse issues may involve us not trusting our patients.

The signs and symptoms of child sexual abuse that you should think about include (see table 1):

• What the child says. Always take disclosures very seriously

• What the child does, how he or she behaves, including sexualised behaviour, for example

• What we find on examination. If you see anything that suggests to you that the child has been sexually abused, seek help from an expert. However, clinical findings are rare and may be present in as few as

5 per cent of cases,1 and their interpretation requires specialist training and ideally a colposcope – and this is the reason there are no clinical photographs with this article.

Further, if there is a recent history of sexual abuse, examination by the

non-expert will compromise forensic evidence. The GP should therefore refer the child urgently and only do what is immediately necessary to resuscitate or ensure the safety of the child.

You will also need to consider the age of the child; the way in which sexual abuse presents varies with age. A young child may not be able to verbalise and may exhibit nightmares, anxiety or fearfulness. An older child may be too frightened or feel too guilty to talk about their problem and may express their pain through aggressive sexualised behaviour,

self-mutilation or prostitution, or they may be withdrawn and socially isolated.

Both boys and girls are sexually abused and perpetrators can be male or female. Children with a disability are more vulnerable and are more likely to suffer abuse of all kinds, and may be less able to talk about what has happened. They may show unusual behaviour patterns as a result.

Interpretation is not easy. For example, vulvovaginitis presents relatively commonly in the general practice setting. A high proportion of young girls who have been sexually abused will have vulval symptoms but vulvitis is also a common and often innocent part of childhood.

What action should the GP take?

The first question must always be: is this child safe?8 In particular, if there is associated physical abuse in a young child, you should be very concerned about the immediate safety of the child.

If you think a child is not safe, then you need to act quickly to ensure their safety. Refer the child to social services urgently by phone. If the child is injured or ill, he or she may need hospital treatment or admission as well.

Put the child's needs first. As family doctors, we have to care for the child and their family. When there is a child protection concern, under the ‘Paramountcy Principle' we must put the needs of the child above all others.

Respond with appropriate speed. If the child is not in immediate jeopardy (this is often the case in sexual abuse), you have time to gather information and to consult with colleagues, such as named or designated professionals.

The detail of what you will do depends on the presentation. A recent history of serious sexual assault needs a rapid response. If you suspect a serious crime has been committed, you will have to involve the police and social services. However, a concern about sexualised behaviour needs careful thinking-through and discussion rather than immediate action.

Gather information from the child and family. You can discuss your concerns with the parents and the child (as appropriate), unless doing so would put the child at risk. If you suspect the parent presenting the child is the perpetrator (but remember this will be relatively rare), you will need to be circumspect in your questioning as there is a risk of the child being ‘coached' in his or her story.

Gather information from the practice team. Ask other doctors in the practice and the health visitor or school nurse, carefully check the notes of other household members for concerns. For example, there may be other concerns about the welfare of other children in the household; there may be domestic violence, or concerns about drug or alcohol misuse, or a history of mental ill health in the parents.

Make a clear and careful note of your concerns. Good note-keeping is essential. Record this and all other contacts, whether by phone or face-to-face, and think about whether you need to record anything in other household members' notes (children, parents).

Know your local arrangements. Local arrangements for advice and referral will vary. It is wise to find out what these are before you need them. Check the child protection register. There may be other concerns about the child: you will not know about these unless you check.

Seek advice from your named or designated doctor or nurse, or from social services. You can do this anonymously, and therefore avoid consent issues. You can also seek advice from social services without identifying the child.

You can ask for a medical opinion. This will usually be from your community paediatrician or in some areas, a hospital paediatrician.

If you still think there is a child protection concern, make a referral to social services. Before making a referral, however, you should usually seek consent of the parent or child, if this is appropriate. You can act without consent if seeking this might lead to further harm to the child or if consent is withheld and you have reason to suspect child abuse. You should make a referral by phone, followed up in writing within 48 hours. You should expect a response from social services within one working day. If you have heard nothing after three days, contact them again to find out what is happening.

Good safety-netting is essential: follow cases up, make sure what you expect to happen actually does take place. If it does not, ask your named or designated doctor or nurse for advice. If you think your concern has not been understood, talk to the social worker again. Assessing and managing any child protection issue requires a multi-agency approach.9 You need to know about and follow your local inter-agency procedure. If you are not sure about this, the named and designated doctors and nurses and social services are there to help you.

You have a continuing role, and your responsibilities do not stop at referral. You have a role in the assessment and continuing management of the problem, and need to think about how you will contribute to this.

How can the GP distinguish between abuse and normal teenage behaviour?

More than one in four young people will be sexually active before they reach the age of 16. We know that young people under 16 are the group least likely to use contraception or to seek sexual health or contraceptive advice. If they do, they will be most likely to consult primary-care services. The biggest deterrent to not seeking advice and help are worries on the part of young people that their right to confidentiality will not be respected. (See table 5).

When making decisions to advise or treat under-16s, GPs need to ask themselves whether or not the young person is competent to consent to treatment and whether or not their relationship is abusive or coercive. The Department of Health has issued helpful advice on this and has confirmed the importance of ‘Fraser Guidelines'.10

Knowing whether or not a relationship is abusive or coercive can be very difficult and, given young people's very strong feelings about confidentiality, GPs will have to strike a balance between respecting a young person's privacy and enquiring about their relationship so that an assessment can be made.

Sadly, the problem of coercive or abusive relationships involving a young person is all too common. Research tells us that 5 per cent of young people aged 13–15 have ‘consensual' sexual activity with an adult aged five or more years older than they are.2

Between a quarter and a third of sexual abusers are themselves juveniles. A troubled teenager in an unwanted and possibly abusive sexual relationship will usually need a slow, patient response that builds trust. Dealing with adolescents is particularly challenging; generally, GPs should try to build trust and make a referral with consent, rather than act in a hurry.

Difficult decisions will also have to be made when it comes to striking a balance between respecting confidentiality and sharing and seeking information from other agencies. GPs may be faced with making decisions with incomplete information. Where there are concerns about a relationship, advice should be sought from named or designated professionals.

The Sexual Offences Act 2003 (see table 6) confirms that the age of consent remains 16 years old, though it is not the intention of the act to prosecute mutually agreed sexual activity between similar aged teenagers.11

Offering advice and treatment to young people aged under 13 is especially difficult as penetrative sexual activity involving an under 13 is legally rape.

GPs will be under strong pressure to rewport such events to social services, who will have no discretion and have to report this to the police.

What should GPs also think about? You must act in the best interest of the young person when considering whether or not to report sexual activity involving an under 13-year-old to social services or the police.

You have a responsibility both to provide a confidential service to young people and play your part in protecting young people from abuse and neglect.

Under-13s have the same right as any other patient to a confidential relationship with their GP. If a decision is made to share information about a young person, consent should normally be sought.

Existing child protection guidelines must be used if abuse or neglect is suspected. Reporting of sexual activity involving an under-13 to social services is not mandatory.

Provided there are not issues around collecting forensic evidence (such as when there has been a sexual assault) GPs can offer treatment, such as sexual health advice or contraceptive treatment, prior to advice being sought, provided the young person is able to give competent consent to treatment.

Sexual activity in under-13s is relatively rare. These cases are usually complicated and GPs must consult with colleagues with expertise in this area, such as a named or designated professional.

References

1 Heger A, Tieson L et al. Children referred for possible sexual abuse: Medical findings in 2384 children. Child Abuse Neglect, 2000;26:645–59

2 Child Maltreatment in the United Kingdom: A study of the prevalence of child abuse and neglect. London:NSPCC;2000. www.nspcc.org.uk/html/home/

informationresources/hiddenchildabusesurvey.htm

3 The Role of Primary Care in the Protection of Children from Abuse and Neglect. A Position Paper for the Royal College of General Practitioners. Prepared by Professor Yvonne H Carter and Dr. Michael J Bannon, London: RCGP, 2002 (Endorsed by RCPCH, NSPCC, British Association of Medical Managers and the NHS Confederation). www.rcgp.org.uk

4 The Victoria Climbie Inquiry. Report of an Inquiry by Lord Laming. Presented to Parliament by the Secretary of State for Health and the Secretary of State for the Home Office by Command of Her Majesty. London:The Victoria Climbie Inquiry;2003.

www.victoria-climbie-inquiry.org.uk

5 Smith D, Pearce L et al. Adults with a history of child sexual abuse:evaluation of a pilot therapy service.

BMJ 1995;310:1175–8

6 Working together to safeguard children 2006. London:Every Child Matters;2006. tinyurl.com/plwg3

7 What to Do if You Are Worried A Child Is Being Abused. DH 2003. tinyurl.com/nar2b

8 Framework for the Assessment of Children in Need and their Families. Department of Health, Department for Education and Employment, Home Office. London:The Stationery Office;2000. tinyurl.com/68ept

9 Best Practice Guidance for Doctors and other Health Professionals on the provision of advice and treatment to young people under 16 on contraception, sexual and reproductive health. London:DH;2004 tinyurl.com/rdv2w

10 Sexual Offences Act. London: Home Office, 2003 www.opsi.gov.uk/acts/acts2003/20030042.htm

Further reading

1 Protecting Children from Abuse and Neglect in Primary Care. Bannon MJ, Carter YH (eds) Oxford: Oxford University Press, 2000

2 Child Abuse and Neglect. A clinician's handbook. Hobbs C, Hanks H et al. 2nd edn. London: Churchill Livingstone, 1999

3 Child protection in Primary Care. Polnay J. (ed) Oxford: Radcliffe Medical, 2001

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