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]}