SEXUAL ABUSE

• Jurisdiction: Australia

Introduction ................................................................................................... [41C.400]

The law.......................................................................................................... [41C.420]

The health service ......................................................................................... [41C.440]

The conduct of the medical examination ...................................................... [41C.460]

Colposcopic and other examinations ............................................................ [41C.480]

Procedures to minimise DNA contamination during sample collection ........ [41C.500]

Rape kits ....................................................................................................... [41C.520]

Female genital examination findings ............................................................ [41C.540]

The labia and vaginal vestibule .................................................................... [41C.560]

The posterior fourchette and fossa navicularis ............................................. [41C.580]

The hymen .................................................................................................... [41C.600]

The perineum ................................................................................................ [41C.620]

The urethral orifice ........................................................................................ [41C.640]

The vagina .................................................................................................... [41C.660]

Male genital examination findings................................................................. [41C.680]

Anal and peri-anal examination findings....................................................... [[41C.700]

Conditions mimicking child sexual abuse ..................................................... [41C.720]

Lichen sclerosus et atrophicus (LS&A) ......................................................... [41C.740]

Sexually transmissible infections (STIs) ....................................................... [41C.760]

Vertical transmission ..................................................................................... [41C.780]

Consensual sex ............................................................................................ [41C.800]

Autoinoculation .............................................................................................. [41C.820]

Accidental transmission ................................................................................ [41C.840]

Parenteral transmission ................................................................................ [41C.860]

Fomite transmission ...................................................................................... [41C.880]

Interpretation of laboratory tests ................................................................... [41C.900]

[41C.400] Introduction

Child sexual abuse (CSA) is the involvement of dependent, developmentally immature children and adolescents in sexual activities which they do not fully comprehend and to which they are unable to give informed consent. The sexual abuse violates the social taboos of family roles, is discordant with community standards and reflects an imbalance of power between the perpetrator and the child: Finkel (2001). In simplest terms, CSA is the use of a child for sexual gratification by an adult or a child or adolescent in a position of power. Generally, CSA has a very different dynamic to physical abuse; the latter is usually an impulsive act associated with a lack of control while CSA is often premeditated and planned.

CSA includes a wide range of activities, including exhibitionism, voyeurism or the touching of children's breasts and genitals as well as penetrative events. Over a period of time, perpetrators may groom and coerce children into more intrusive degrees of sexual activity.

CSA is surrounded by secrecy, disbelief and denial. Perpetrators - through their authority, seductiveness, threats or some combination of these - may prevent a child, however frightened and aware of wrongdoing, from reporting the abuse for lengthy periods.

Allegations of abuse may become evident when:

1. The child informs others about the event. Such a disclosure might be to a trusted adult or to a sibling or peer who then passes on this information.
2. There are concerns that the child is at a high risk of having been abused. This might occur if a sibling alleges sexual abuse or a known sex offender is found cohabitating with a child.
3. The child develops a range of behavioural or physical symptoms that raise the possibility of abusive events having occurred. Such presentations might include genital symptoms or injuries, sexualised behaviours and regression in behaviour, developmental milestones or school performance. Note that non-specific behavioural changes are common and may have their foundation in a range of reasons and circumstances, including, but not requiring exposure to, traumatic experiences and circumstances. It is also noteworthy that sexualised behaviours might exist for a range of reasons. Although some sexualised behaviours are more commonly seen in sexually abused children than non-sexually abused children, there are no sexualised behaviours that discriminate between children who have been sexually abused and those who have not: Freidrich (2001); Kellogg (2010).
4. A parent or carer suspects another adult is sexually abusing the child. Not infrequently such allegations are made in the setting of conflict between the adults or during a custodial dispute.

[41C.420] The law

There are many differences among jurisdictions pertaining to some elements of sexual offences against a child. In the consideration of medical-related matters, the following may be pertinent:

1. Age: Legislation will indicate a chronological definition of a child. Valid consent for a sexual act may not be applicable below this age. In many jurisdictions an age gap exists between the age at which the law recognises individuals' capacity to consent to sex (commonly 16 years) and the age of majority when individuals are legally recognised as adults (almost universally 18 years).
2. Gender: Non-gender-specific sexual offences legislation is well established. This will include provisions for offences (and offenders) for male or female gender and for intersex and transgender individuals.
3. Consent: The capacity to consent to sexual activity may have specific application to children. In addition to age, the child's capacity to consent (or even understand the implications) may be further reduced by an intellectual disability and some forms of active psychiatric conditions.
4. Penetration: The types and degree of penetration required as an element of these offences has some legislative variation. Use of the terminology "penetration to any extent", indicating penetration of the labia (but not necessarily the hymen), the lips (oral) or anal margins is required to satisfy this element.

Penetration is an emotive word which means different things to different people. A child, particularly a very young one, may have a limited capacity to understand the concept as to whether or how far something has "penetrated" or "been put inside"; for instance, uncertainty about penetration of an orifice or "penetration" between the thighs and between the buttocks: Finkel and Giardino (2009). The word may also be wrongly associated with outdated concepts such as "virginity" and "virgo intacta".

5. Offences: In addition to the "penetrative offences", there are other sexual offences referred to in sexual offences legislation. Proof of some of these offences may be dependent on the presence of corroborative evidence established during a medical assessment. For example, injuries to breasts or inner thighs might support allegations of indecent assault or assault with sexual intent and toxicological analysis may provide indications of covert drug administration for the purposes of sexual activity. More recently, many jurisdictions have enacted legislation in relation to adults travelling to other countries for the purpose of sexual activity with children, child-trafficking, internet-related and media-related sexual crimes, grooming children for sexual activity as well as mandating the reporting of adults' knowledge of child sexual offences to police or other authorities.

[41 C.440] The health service

A comprehensive and holistic health and welfare assessment should be accessible to all children who present in this situation. This should be undertaken by practitioners with training and experience in this specialised field and within a service specifically established to provide this role. A detailed knowledge of genito-anal anatomy, patho-physiology and terminology are fundamental to practice in this field. In addition, practitioners should possess...