This article will deal primarily with the medical assessment of alleged sexual abuse in female adolescents; however, there are many similar considerations when assessing male adolescents. It can be confronting to treat adolescents who have experienced sexual abuse and the clinician should aim to reduce further harm to the young person. In addition, opportunistic healthcare should be provided, if possible.

In many centres, there are specific services for child and adolescent victims of sexual abuse, with appropriate clinical and forensic expertise. General clinicians should contact their local service for advice; often the young person is referred onwards to these services for forensic assessment.

Sexual abuse includes a broad collection of acts, including fondling, other non-penetrating acts, sexual exploitation and penetrating acts. Adolescence can be a vulnerable period of life, and there are certain groups of adolescents who are particularly at risk of sexual abuse (including, but not limited to, homeless young people, adolescents in residential care and adolescents with substance use disorders).

Mandatory reporting

In regards to sexual abuse, sexual assault and intimate partner violence, mandatory reporting is an important consideration. In all Australian states, doctors are considered mandatory reporters. The age at which an adolescent is considered a ‘child’ varies between states, therefore it is best to talk to child protective services and police in your state if you are not sure.

Confidentiality and approach

A respectful and non-judgmental approach should be used when providing medical care for adolescent patients. Introduce yourself and explain your role. Maintaining confidentiality is essential; explain what this means. Young people have the legal right to confidential healthcare unless they cannot be considered a mature minor and/or there is a significant concern of risk, such as harm to self, threat of homicide or physical or sexual abuse. The young person may have a support person present; in most cases a counsellor from a sexual assault support service should attend. Document who is present for history-taking and examination. A group of patients that may seek medical care for the assessment of alleged sexual abuse are those in the care of child protective services. This may be a young person in foster care or residential care. Child protective services should be notified if the patient arrives unaccompanied, but only given information if the young person explicitly gives permission or suggests it (this does not exclude concerns regarding risk, such as in the case of sexual abuse).

Consent

Before taking a history of the alleged sexual abuse or examination, the doctor must take informed consent. ‘It is generally accepted that most young people over 16 are capable of giving their own informed consent. Those younger may sometimes be considered mature minors. The mature minor principle has been confirmed in Australian common law, such that minors (< 18 years) may be able to give informed consent if they have sufficient understanding and intelligence to enable full understanding of what is proposed.’¹ One way to ensure this process is clear is to use a consent form specifically for adolescents (including the explanation of the term ‘mature minor’). Talk about what will happen during the anogenital examination, requirements of mandatory reporting (including the provision of a report to child protective services and the police), the provision of forensic specimens to the police (often these cannot be ‘retracted’ once given as evidence) and, in some cases, video recording for peer review and the likelihood of ongoing medical care and treatment.

When taking informed consent, remember to consider whether the young person is able to give consent if affected by drugs or alcohol. Another consideration is the young person’s mental health. Persons with mental health conditions who require involuntary admission to a mental health facility are still able to consent to medical procedures in most cases, but should understand the assessment as per informed consent principles. Likewise, some young people may wish not to proceed with the history and examination process. Rather than causing more distress in an already vulnerable and distressed young person, offer medical care.

History

Taking a history is usually the next step in the process. In some cases, police officers may have already interviewed the young person and can provide details pertinent to the collection of forensic specimens. It is not the role of the doctor to investigate the circumstances of the alleged sexual assault, but knowing when the alleged assault occurred and where on the body forensic specimens will need to be collected is important to forensic specimen collection.

Ensure that the young person is not suffering injuries that need urgent attention (such as serious bleeding) as treating these needs to be prioritised. Apart from the where, when and what of an alleged sexual assault, document what the adolescent says in their own words. Often this requires writing as the history is taken, which can be off-putting. There are time limits for the appropriateness of certain forensic specimens. Determine whether or not the patient has washed, changed clothes, is menstruating, passed urine, defecated, brushed teeth and last had sexual intercourse.

Often young people who have experienced sexual abuse are vulnerable in other aspects of their wellbeing and may not seek medical attention apart from this interaction. I usually begin a medical history by documenting who the young person lives with, including siblings and parents. Past medical history, allergies and immunisation status should be documented. Adolescents who have complex psychosocial situations may miss immunisations. A menstrual history should be taken, including onset of menses, regularity, heavy or painful periods, day of cycle, contraception use.

HEADSSS screen (psychosocial screen)

Taking a psychosocial history is an important aspect of interacting with young people. Be upfront that you will be asking these questions and will respect the principles of confidentiality.

Home – who, where, recent moves, relationships, violence
Education and employment – where, attendance, year, performance, relationships, bullying
Eating – weight, dieting
Activities – sport, groups, clubs, parties, screen use and social media safety
Drugs and alcohol – cigarettes, alcohol and illicit drug use, how these are financed
Sexuality – close relationships, sexual experiences, current partners
Suicide, depression and self-harm – include other aspects of mental health such as anxiety, current risk of suicide and self-harm, any input such as psychologist or school psychologist
Safety from injury and violence – including criminal behaviours, exposure to violence in relationships¹

Often the adolescent may not wish to discuss aspects of the HEADSSS screen when their parent or guardian is present and it is important to provide them with an opportunity for privacy.

Anogenital exam and forensic specimen collection

Occasionally, anogenital examination and/or forensic specimen collection may not be required. If you have concerns regarding this, there are tertiary on-call services for paediatric sexual assault who you can discuss the case with before proceeding with examination. As for adult forensic specimen collection, document who is in the ‘clean room’. A chaperone of the adolescent’s choosing should be present. The anogenital exam is a particularly triggering process for most young people who have been sexually assaulted.

Inform the young person that they have the right to end the examination at any point. Begin with forensic specimen collection. There are various kits used for this and it is important to maintain DNA integrity throughout the process (gowns, changing gloves with each specimen collected and documentation of each specimen). There are a number of sites on the body and mouth from which specimens are collected. Clothes are often collected as evidence and the adolescent should be offered clothing (usually kept in most sexual assault clinic rooms) to wear following the examination.

Collecting forensic specimens from the anogenital region is generally performed prior to video recording to assess injuries. In most adolescents, speculums are not used as they are not well tolerated. Occasionally, speculum use should be attempted if a cervical specimen is required (for example, if it is more than 72 hours following the alleged sexual assault). In younger adolescents, be mindful that touching the hymen with swabs may be painful and it may not be possible to perform high vaginal swabs in this case.

Once forensic specimens are collected, proceed to assessing the adolescent for anogenital injuries. A video-colposcope is helpful to provide lighting, magnification and recording the examination findings for peer review. A helpful article outlining the significance of findings, in particular, normal variants is referenced.² Look for bruising, petechiae, erythema, abrasions, the appearance of the hymen (including deep notches) and tears. These can be documented on body diagrams that may be supplied in some forensic kits or downloaded (the Victorian Forensic Paediatric Medical Service has these available on their departmental site accessible to the public).³ Many adolescents have fears regarding being ‘damaged’ or no longer being ‘normal’; this can be alleviated by a caring medical professional explaining the findings of the anogenital examination to them. It is also important to explain that not finding injuries does not mean that a sexual assault has not occurred. An alleged sexual assault may be drug-facilitated, in which case urine and blood toxicology samples should be provided to the police.

Management and follow up

Once the examination is complete, offer urine and blood testing for pregnancy and STI screening (include hepatitis B immunisation status). Provide STI prophylaxis (azithromycin 1g), pregnancy prophylaxis if within 72 hours of sexual contact (Postinor) and HIV prophylaxis for high-risk sexual contacts. Consider offering hepatitis B immunisation. Follow-up pregnancy testing and STI testing should be arranged.

Ensure the young person’s mental health and wellbeing is considered following your assessment and refer to appropriate services when necessary. It may be appropriate to get consent to contact the adolescent’s general practitioner for follow-up testing. Any other injuries should be documented, photographed if necessary and treated. Make sure the adolescent is going in to a safe environment following your assessment.

1. RCH Clinical Practice guidelines. Engaging with and assessing the adolescent patient: RCH Clinical Practice Guidelines. Available from: www.rch.org.au/clinicalguide/guideline_index/Engaging_with_and_assessing_the_adolescent_patient/.
2. Adams JA, Kellogg ND, Farst KJ, et al. Updated guidelines for the medical assessment and care of children who may have been sexually abused. J Pediatr Adolesc Gynecol. 2016;29(2):81-7.
3. Victorian Forensic Paediatric Medical Service and The Royal Children’s Hospital Melbourne. 2017.
   Available from: www.rch.org.au/vfpms/tools.