Our Practice Improvement Advisor for Health, Dr Michelle Cutland, reflects on improving understanding of the paediatric medical examination for concerns of CSA and the importance of professional curiosity. Michelle also works as the Clinical Director for the Children's Service at the Bridge SARC Avon & Somerset, where she continues to provide frontline practice and develop regional services.
When there is a disclosure or concern about child sexual abuse, the child may be brought for a medical examination. These are usually undertaken in a local or regional Sexual Assault Referral Centres (SARC), children’s clinic or other facility settings. This consultation and examination is an opportunity to holistically access the child’s health and wellbeing as well as identifying potential supportive physical findings and collecting forensic samples.
In my own practice and from colleagues in the field we know that agency partners can be cautious about referring children for medical examinations which is, in part, linked to a lack of knowledge on the role and purpose of these examinations. I recently led a piece of work to examine the role and purpose of medical examinations when there are concerns about CSA and provide an evidence informed overview on what a medical examination is and how it can help. The benefits of medical examinations include identifying forensic and evidential findings, providing a holistic assessment of the health and wellbeing of the child, addressing unmet general, mental and sexual health needs, assessing risk and providing feedback and reassurance to children and carers.
Informative and practical resources
Social workers and police officers understandably want to support and prepare children and their parents and carers for the medical examination and yet as non-health professionals they may well have limited insight into the process and approach and the broad benefits for the child. To support those professionals with responsibility for referring children for medical examinations we have prepared a short (10 minutes) informative film explaining the purpose and process We encourage all those working in the field of safeguarding to watch and share it with colleagues.
In addition to building confidence amongst frontline professionals, other helpful ways that children, young people and carers can be prepared for medical examinations is with information leaflets such as these.
Some SARCS and other health providers have other age appropriate resources that can be used to help put children at ease such as this animation from Newcastle Hospital on what to expect at the children’s and young person’s clinic.
Improving our understanding of child sexual abuse
As well as providing direct support to the child, the paediatric medical examination is also a significant opportunity for us to gain valuable insights into the nature and impact of CSA in a locality.
As clinical lead for a SARC I found the recent study by CSA centre with Saint Marys SARC in Greater Manchester to be enlightening about just how much data is collected within our case files that we are currently not making use of. The study revealed the extent of the insights that could be gained from the information we already collect if we recorded the data systematically and in a way that was easy to extract and analyse.
This impressive dataset tells us much, not just about those accessing the SARC’s service, but also about the contexts of abuse and those suspected of committing offences. A striking finding for me was the number of young people with mental health needs reported; 35% reported self-harm and 12% reported suicidal attempts by the time of their medical examination.
Other research such as this informative cohort study from Khadr et al, the only one of its kind in the UK, based at the Havens in London highlights that the mental health needs remain significant for at least 6 months after assault. It also showed 8% of the young people sampled reporting re-victimisation in the 6 months following the assault.
Clearly we need to get mental health pathways right in a timely and responsive manner to best support victims and their families. This is recognised by NHS England’s commitment in their 2019 sexual assault strategy that anyone who has experienced sexual assault or abuse will get trauma care throughout their lifetime.
All specialist health providers need a solid evidence base that is grounded in practice to help them do their work in a safe, supportive way and to ensure that children and young people are best cared for. Resources such as Royal College of paediatrics and child health’s (RCPCH), The Faculty of Forensic and Legal Medicine’s (FFLM), Royal college of Physicians of London’s (RCP) and American Academy of Pediatric’s (AAP) ‘the physical signs of child sexual abuse’ are invaluable. This evidence-informed review first originated from the recognition of a lack of knowledge in the field so its roots are embedded in learning from practice. It enables specialist practitioners to be supported and confident in their findings, maintain standards and assist the courts in investigative processes.
Being professionally curious
Those children and young people who do have medical examinations, however, remain the minority of those that experience CSA; it is currently the case that most children will never disclose sexual abuse, remain unidentified by services and so do not access help and support. As health professionals we hold a position of trust with our patients and have a responsibility to be professionally curious when we have any concerns about CSA or wider safeguarding.
Children and young people who have experienced CSA are likely to access health services throughout their lives and in a number of ways; within health we must continue to be vigilant to the number of ways they may present. These young people may be seeking contraception or sexual health screening, perhaps they are presenting or brought by carers for help with deliberate self-harm or anxiety. Perhaps the way they access health is seemingly unrelated to CSA at first glance with complaints of headache or disordered eating or substance misuse or ‘disruptive’ behaviours.
The first step to making sure that children who have experienced CSA can access support is identifying their need. All practitioners need to be professionally curious; if we are concerned about a child or young person we are seeing, we are encouraged to not just think – but to ask. The ‘not just a thought’ website provides professionals with help to get started with these all-important conversations with young people and these practical resources from the NSPCC help us nurture the right skills to let children know you're listening.