Potentials and Limitations of the Medical Approach - Child sexual abuse
As a normal physical examination is frequent in victims of CSA, the forensic aspect of the evaluation cannot be the primary or exclusive goal. A medical approach to CSA has to reflect the potentials but also the limitations and possible risks of the medical evaluation. It is crucial that the needs of the child have absolute priority over the desire to collect forensic evidence. The physical examination of sexually abused children has the potential to be an emotionally invasive and distressing procedure (‘re-victimization’) if not performed in a qualified and empathetic manner.
Although scientific data to support this view is lacking, the possibility is evident and appears to be a concern for referring non-medical professionals, possibly influencing referral patterns and selection of patients for medical evaluation [Bowen and Aldous, 1999]. This again underscores the paramount importance of interprofessional communication and cooperation. An essential prerequisite of examining possibly abused children in a non-traumatizing manner is to avoid any force or coercion. The experience of specialized child protection centers indicates that well-documented examinations help to avoid repetitive examinations and thereby may even prevent further potential trauma.
The emotional response to the medical examination is probably not only influenced by factors inherent to the examination situation itself, but also by multiple other variables, such as preexisting factors (e.g. general anxiety, previous experiences with the medical system, the age and developmental status of the child) and on the other hand the characteristics and severity of the abuse [Finkel, 1998; Britton, 1998]. Several studies with small samples and the impression of experienced experts in the field indicate that most children seem to cope well with the examination [Lazebnik et al., 1994; De San Lazaro, 1995; Steward et al., 1995; Gully et al., 1999; Waibel-Duncan and Sandler, 2001; Palusci and Cyrus, 2001].
Children who have disclosed sexual abuse should be evaluated for injuries, anogenital infections, sexually transmitted diseases or pregnancy and treated accordingly. Because a majority of abused children have an altered and distorted body image [Joraschky, 1997] it is of paramount importance to reassure the child that its body is normal, physically undamaged, and intact or that it will heal. Doctors, especially pediatricians, who define disease or well-being in other medical settings are powerful authorities in this respect. They can help to relieve feelings of physical abnormality and initiate the process of recovery (’primary therapeutic aspect of the medical examination’). Thus the medical examination has an enormous potential to incorporate a therapeutic message into the diagnostic procedure.
In cases of suspected CSA, the cooperation with other professions is crucial.
The medical examination may contribute valuable aspects to a multidisciplinary approach. Due to evident reasons mentioned above however, a medical examination can never exclude the possibility of CSA. Therefore, child protection professionals need to know each other and cooperate in mutual respect.
They also need to know their respective potentials and limitations. Medical involvement in CSA cases does not only depend on the clinicians’ engagement and skills but also in the confidence the child-protection and law-enforcement system develops in the clinician [Finkel and De Jong, 2001].
Revision date: June 14, 2011
Last revised: by David A. Scott, M.D.