Child sexual abuse and assault assessment — branching viva

Stem

The examiner will test whether you can defend the tempo of the assessment, the meaning of a normal examination, the interpretation of specific findings, and the acute bundle — all under pressure. [1] [2]

Branch 1 — Tempo and triage

Examiner: A seven-year-old presents at midnight after disclosing that her mother's partner touched her genitals earlier that evening. How do you decide the tempo? [1]

Strong answer: The first decision is acute versus non-acute. The alleged contact was earlier today, so she is within the forensic window (typically up to 72 hours) and this is an acute presentation. Resuscitation and analgesia come first, then consent and chaperone, then the forensic interview and examination, then the time-limited elements — the forensic kit while the window is open, STI baseline and post-exposure prophylaxis as indicated by her pubertal stage, and a safety plan and mandatory report. A non-acute presentation, by contrast, is elective: no kit, unhurried examination, STI testing where indicated, and mental-health and safety planning. [1]

Examiner: Where does the forensic kit sit in your priorities? [1]

Strong answer: Below resuscitation, analgesia and immediate safety. The kit is collected only if within the window, with explicit consent and an unbroken chain of custody. It is a time-limited element, not the goal of the encounter — the history and the child's safety are. [1]

Branch 2 — The normal examination

Examiner: The examination, including the posterior hymenal rim with separation and traction, is normal. Does that exclude abuse? [2]

Strong answer: No. A normal examination never excludes abuse. In Adams' legally confirmed series, the majority of children had normal or nonspecific findings, because hymenal tissue heals rapidly, most contact is non-penetrative, and disclosure is delayed. The normal exam is expected and expected to coexist with a true disclosure. [2]

Examiner: So what does carry the diagnosis if the exam does not? [4]

Strong answer: The history, taken once and well by a trained forensic interviewer using a structured protocol such as the NICHD protocol, together with the overall context and the multi-agency judgement. The clinician's job is to listen and document, not to re-interview, because repeated and suggestive questioning contaminates the account. [4]

Branch 3 — Finding interpretation

Examiner: Name a finding that is specific for trauma or contact, and a common mimic you must not over-call. [1]

Strong answer: A specific finding is a full-thickness transection of the posterior hymenal rim between 3 and 9 o'clock, or absent posterior hymenal tissue — these are diagnostic of trauma or contact and are rare. A common mimic is lichen sclerosus et atrophicus, which produces pale atrophic 'figure-of-eight' plaques that bruise and fissure; another is a straddle injury, which is external, anterior and asymmetric and follows a clear fall onto a hard edge. Over-calling a normal variant such as a midline posterior notch or a vestibular band destroys a family. [1]

Examiner: What about a prepubertal child with gonorrhoea? [1] [3]

Strong answer: A confirmed Neisseria gonorrhoeae infection in a prepubertal child, once perinatal transmission is excluded, is a specific finding strongly suggestive of — and may be diagnostic of — sexual contact. It warrants a full assessment and a mandatory report; fomite or toilet-seat transmission is not a credible explanation. [1] [3]

Branch 4 — The acute adolescent bundle

Examiner: A fifteen-year-old presents six hours after assault by an unknown assailant. Walk me through the bundle, naming the time-limited elements. [3]

Strong answer: Resuscitation and analgesia first. Consent (she is a mature minor) and chaperone. Forensic interview and examination. Then the time-limited elements: the forensic kit within 72 hours; emergency contraception — levonorgestrel 1.5 mg orally effective up to 72 hours, or ulipristal 30 mg up to 120 hours, or a copper intrauterine device up to 5 days; STI baseline then empiric prophylaxis covering gonorrhoea, chlamydia and trichomoniasis; HIV post-exposure prophylaxis started within 72 hours if the exposure is high-risk; and hepatitis B vaccination with immunoglobulin if indicated. Close with psychological first aid, the mandatory report, a safety plan, and a two-week and two-to-three-month follow-up. [3]

Examiner: How do you decide on HIV post-exposure prophylaxis? [3]

Strong answer: By risk assessment of the perpetrator, the act and the time elapsed. When the assailant is known or likely to be HIV-positive, or the act is high-risk, start a three-drug regimen within 72 hours with infectious-disease input and follow-up serology over 28 days. [3]

Branch 5 — Confidentiality and reporting

Examiner: She asks you to promise not to tell anyone. What do you say? [1]

Strong answer: I do not promise secrecy I cannot keep. I state, before the interview, that what she tells me is confidential but that I have a legal duty to act when I am worried a young person has been harmed, including telling child-protection services. I frame this as my job to keep her safe, not as a betrayal, and I keep her as the decision-maker wherever she is competent. [1]

Examiner: Who do you report to, and who owns the follow-up? [1]

Strong answer: I report reasonable belief of child sexual abuse to child-protection services and, where indicated, police, who determine the statutory response. I own the medical follow-up — the two-week and two-to-three-month reviews, the therapy referral, and the longitudinal relationship that so often falls to the general paediatrician. [1]