Child sexual abuse and assault assessment — formative SAQs

SAQ 1 — The non-acute assessment and the normal examination (10 marks)

A six-year-old girl is referred by her school nurse after a tentative disclosure that her mother's boyfriend "touched her bottom" around two months ago. She is otherwise well. The school has already interviewed her twice. [1]

Questions

1. Outline how you would approach this assessment, including the setting, who should take the history, and the order of the examination. (4 marks) [1]
2. The ano-genital examination, including the posterior hymenal rim with labial separation and traction, is completely normal. Explain what this means and what it does not mean for the diagnosis. (3 marks) [1] [2]
3. State your obligations after this assessment, including any follow-up. (3 marks) [1] [4]

Model answer

Approach to the assessment (4). Treat this as a non-acute, elective assessment — the alleged contact is around two months old, so there is no forensic window and no urgency. Provide a quiet, private setting with a competent examiner and a chaperone. The history should be taken once, by a trained forensic interviewer using a structured protocol; the clinician listens and documents rather than re-interviewing, because the child has already been interviewed twice and repeated questioning contaminates the evidence and distresses her. State the limits of confidentiality, including mandatory reporting, before the interview. Conduct a general examination for growth, skin and signs of other maltreatment, then a careful ano-genital examination in the supine frog-leg position with labial separation and traction, adding knee-chest if the hymen is not well seen, and colposcopy with photo-documentation for peer review. [1]

Interpreting the normal examination (3). A normal examination does not exclude sexual abuse. In Adams' study of legally confirmed abuse the majority of children had normal or nonspecific findings, because hymenal tissue heals rapidly, most contact is non-penetrative, and disclosure is usually delayed. The normal examination is therefore expected and expected to coexist with a true disclosure; the disclosure and the overall context carry the diagnosis, and a normal exam never closes the case. [1] [2]

Obligations and follow-up (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. Arrange a two-week review and a two-to-three-month review that repeats serology where indicated and confirms the safety plan is working, because missed infections and healing findings often emerge at follow-up. [1] [4]

SAQ 2 — The acute adolescent assault bundle (10 marks)

A fifteen-year-old girl presents six hours after a sexual assault by an unknown assailant in a park. She is post-menarchal, not on contraception, haemodynamically stable, and her HIV status is negative; the assailant's HIV status is unknown but the act was high-risk. [3]

Questions

1. List the elements of the acute management bundle, in order, naming the time-limited elements. (5 marks) [1] [3]
2. Describe the emergency contraception and STI prophylaxis you would offer, with agents and the time windows that govern each. (3 marks) [3]
3. Explain how you would handle HIV risk and the consent/confidentiality aspects of the consultation. (2 marks) [3]

Model answer

Acute bundle in order (5). First, ABCDE resuscitation and analgesia — although she is stable now, this is checked first, and any acute injury takes priority over the forensic kit. Second, consent (from her as a mature minor and from her guardian) and a trained examiner with chaperone. Third, the forensic interview and the head-to-toe and ano-genital examination. Fourth, the time-limited elements: the forensic evidence kit collected within the 72-hour window with a continuous chain of custody; emergency contraception; STI prophylaxis after baseline specimens; HIV post-exposure prophylaxis risk assessment; and hepatitis B vaccination (with immunoglobulin if indicated) and catch-up HPV vaccination. Fifth, psychological first aid, the mandatory report, a safety plan, and a two-week and two-to-three-month follow-up. [1] [3]

Emergency contraception and STI prophylaxis (3). For emergency contraception, offer levonorgestrel 1.5 mg orally as a single dose, most effective taken as soon as possible and effective up to 72 hours with declining efficacy to 96 hours; or ulipristal acetate 30 mg orally, which is preferred and more effective between 72 and 120 hours; or a copper intrauterine device, the most effective option, up to 5 days. For STI prophylaxis, send baseline NAAT for chlamydia, gonorrhoea and trichomonas plus syphilis, HIV and hepatitis serology, then give empiric prophylaxis covering gonorrhoea, chlamydia and trichomoniasis (for example ceftriaxone, azithromycin or doxycycline, and metronidazole) per the CDC guidance. [3]

HIV risk and consent/confidentiality (2). Because the exposure is high-risk and the assailant's status is unknown, offer a three-drug HIV post-exposure prophylaxis regimen started within 72 hours, with infectious-disease or sexual-health input and follow-up serology over a 28-day course. State the limits of confidentiality — including mandatory reporting — before the interview; a mature minor can consent to examination, testing and contraception, and the consultation is conducted with her as the primary decision-maker wherever she is competent. [3]