Child sexual abuse and assault assessment OSCE — acute adolescent assault and the non-acute normal examination

Station objectives

1. Recognise the acute versus non-acute tempo and prioritise the time-limited elements accordingly. [1]
2. State conditional confidentiality with its mandatory-reporting limits before the interview. [1]
3. Assemble the acute assault bundle in order, naming agents and time windows for contraception and prophylaxis. [2]
4. Interpret and safely communicate a normal ano-genital examination without excluding abuse. [1] [3]
5. Discharge the safeguarding, reporting and follow-up duties. [1] [4]

Candidate brief

You are the paediatric registrar in the emergency department. You have 10 minutes for Station A (acute adolescent assault within the forensic window) and 12 minutes for Station B (non-acute prepubertal child with a normal examination and a safeguarding decision). Examiners score tempo recognition, conditional confidentiality, the completeness and order of the bundle, the interpretation of the normal examination, and the safety of the disposition. [1] [2]

Station A — Acute adolescent assault (within the window)

Setup: A fifteen-year-old girl, seen alone, presents six hours after a sexual assault by an unknown assailant in a park. She is post-menarchal, not on contraception, haemodynamically stable, HIV-negative; the assailant's HIV status is unknown but the act was high-risk. [2]

Expected actions:

• Confirm ABCDE stability and analgesia; recognise this as acute and within the forensic window. [1]
• State conditional confidentiality, including mandatory reporting, before the interview. [1]
• Consent the young person as a mature minor, with a trained examiner and chaperone. [1]
• Order the time-limited elements: forensic kit within 72 hours; baseline STI specimens then empiric prophylaxis covering gonorrhoea, chlamydia and trichomoniasis; emergency contraception (levonorgestrel 1.5 mg up to 72 hours, or ulipristal 30 mg up to 120 hours, or copper intrauterine device up to 5 days); HIV post-exposure prophylaxis within 72 hours given the high-risk exposure; hepatitis B vaccination with immunoglobulin if indicated. [2]
• Close with psychological first aid, a mandatory report, a safety plan, and a two-week and two-to-three-month follow-up. [1] [4]

Common errors the examiner will trap: promising secrecy; deferring resuscitation or analgesia for the kit; omitting emergency contraception or HIV post-exposure prophylaxis; forgetting baseline specimens before prophylaxis; and failing to arrange follow-up serology. [2]

Station B — Non-acute child with a normal examination

Setup: A six-year-old girl is referred after a tentative disclosure two months ago that her mother's partner touched her genitals. The ano-genital examination, including the posterior hymenal rim with labial separation and traction, is completely normal. Her mother asks whether the normal examination means "it didn't happen". [1] [3]

Expected actions:

• Recognise the non-acute tempo: no forensic window, no kit; an unhurried, child-paced examination and a single trained forensic interview. [1]
• Explain to the mother, without over-promising, that a normal examination does not exclude abuse, because hymenal tissue heals rapidly, most contact is non-penetrative, and disclosure is often delayed — most confirmed cases have normal or nonspecific findings. [1] [3]
• State that the disclosure and overall context carry the diagnosis, not the examination. [3]
• Make a mandatory child-protection report on reasonable belief of abuse, agree a safety plan so the child does not return to the alleged perpetrator, and refer for trauma-focused therapy. [1]
• Arrange a two-week and a two-to-three-month follow-up that repeats serology where indicated and confirms the safety plan is working. [1] [4]

Common errors the examiner will trap: concluding "no abuse because no findings"; re-interviewing the child; promising confidentiality; over-calling a normal variant as a specific finding; and discharging the child without a safety plan or follow-up. [1] [3]

Marking domains

• Tempo and prioritisation — acute vs non-acute recognised; resuscitation and the time-limited elements in the right order. [1]
• Communication and confidentiality — conditional confidentiality stated; the young person kept central; the normal examination explained without excluding abuse. [1] [3]
• Clinical bundle — contraception, STI prophylaxis and HIV post-exposure prophylaxis with correct agents and windows; baseline specimens before prophylaxis. [2]
• Safeguarding and follow-up — mandatory report, safety plan, therapy referral, and the two-week and two-to-three-month reviews. [1] [4]