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Rosemary Isaacs Day 2 - Australian Association of Forensic Physicians - The Adolescent Sexual Assault Examination: Medical and Forensic Challenges

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Dr Rosemary Isaacs, Medical Director Sexual Assault and Clinical Forensic Medicine, Sydney & South West Sydney LHDs, Royal Prince Alfred & Liverpool Hospitals, Secretary, Australasian Association of …

Dr Rosemary Isaacs, Medical Director Sexual Assault and Clinical Forensic Medicine, Sydney & South West Sydney LHDs, Royal Prince Alfred & Liverpool Hospitals, Secretary, Australasian Association of Forensic Physicians presented this at the 2nd Annual Forensic Nursing Conference.

This is the only national even of its kind promoting research and leadership for Australia's Forensic Nursing Community. The program addresses future training of forensic nursing examiners, forensic mental health consmers, homicide and its aftermath, ethical dilemmas in clinical forensic medicine, child sexual abuse, providing health care to indigenous patients in the forensic arena and more.

To find out more about this conference, please visit http://www.healthcareconferences.com.au/forensicnursing

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  • 1. Adolescent SA Dr Rosemary Isaacs FRACGP MForensMed (Monash) Medical Director Sexual Assault and Clinical Forensic Medicine RPA and Liverpool Hospitals rosemary.Isaacs@sswahs.nsw.gov.au
  • 2. Teenage presentations: What are the issues • Engaging the adolescent • Family and support • Adolescent genital examination for girls and boys • Promoting safety in adolescents
  • 3. What age is adolescence? • Physical: Pubertal Development • Mental, Emotional and Social
  • 4. Jenny age 15 • Lives with Mother :caring on welfare • Anxiety disorder, anorexia. • Went out with a girlfriend, girlfriend’s boyfriend and a boy known to him • Was left alone with the strange boy to watch videos……. • Told mum when she got home
  • 5. Mandy aged 13 • Very neglected childhood, known to community services • Met a boy-friend on facebook, aged 28 • He travels to where she lives, met her at railway station took her to Sydney • 2 days later mum reports her as a missing person • Brought to SA service by police saying last sex 2 days ago
  • 6. Kara aged 12, yr 7 • Has told mum that step father is having sex with her in his truck. • Mother reports to police • At medical exam Kara tells you her grandfather has also had sex with her when left alone with him in school holidays
  • 7. Josie aged 16, yr 11 • • • • Out somewhere she is not meant to be Raped Goes to police herself Comes to hospital, alone
  • 8. • What can you do to help these teenagers – feel safe – co-operate with the examination – Recover –?
  • 9. Engaging with the adolescent • • • • • • Caring, professional and friendly Listen and respect what they say Silence is ok If possible involve supportive adult Stress value of medical check up They may refuse examination, – Don’t get angry – Stress value of follow up – Leave door open for these confused kids to return
  • 10. • Assist them to evaluate • Is there anyone they can turn too • Reasons they don’t wan to tell their Mum/aunt/older sister/counsellor
  • 11. Essential Elements of Trauma-Informed Child Welfare Practice (adapted from Rady Children’s San Diego) 1. Safe 2. Assist in reducing overwhelming emotion 3 . Help children make new meaning of their trauma history and current experiences • Support positive relationships in their life • Provide support and guidance to child’s family and caregivers • Address the impact of trauma on child’s behaviour, development, and relationships 4. Coordinate services with other agencies.
  • 12. Adolescent Brain Development • Prefrontal cortex – ‘the executive planner of the brain’ – finishes development last (mid 20s-30s) – Weighing risks and benefits, developing strategic thinking and impulse control. • the amygdala – the emotional centre of the brain – can dominate decision making in adolescents – Fight, flight, freeze and freak out, rather than rationality. – misinterpret others’ facial emotions, perceiving fear or nervousness as anger or hostility. www.nwpublichealth.org/archives/s2007/adolescent-brain
  • 13. Adolescent Physical Development • Variable. And a few dark genital hairs can be present before puberty • Physical development can begin at 8 • Girls menarche aged 9-15, average 12 ½ (US) • International variation • Menarche commences 2-3 years after breast budding • Menarche usually commences at Tanner Stage 4
  • 14. Adolescent genitalia
  • 15. Adolescent genitalia
  • 16. Possible speculum use • Small or extra small speculum with a good light source
  • 17. Changes with puberty • Labia minora extend posteriorly to commissure – Become longer and darker • Pigmented, rugated or wrinkly by Tanner 5 • Clear secretions – Increasing from tanner 3 • Hymen becomes – Thicker • May be come tulip shaped or fimbriated – Paler • less vascular – Less sensitive to touch – Signs of transections from pre pubertal abuse may disappear
  • 18. Genital maturation in PubertY stage 2 stage 3 *___-/ z ,/ (+( l"l YI / N/l/ I staq"e 4 / "/ staqe 5 Fig.9.4 Tanner's five stages of male genital maturation' (Stage '1 preadolescence is not shown')
  • 19. Boys… the anus • Genitals: record injury • Medical opinion for Penile or scrotal injury or pain
  • 20. Images removed
  • 21. Sexual Health • Pregnancy • Common STIs in this age group – Chlamydia – Genital warts… HPV • Assailant MSM Others. – – – – – Gonorrhoea Syphilis Hep B, Hep A, HIV Trichomonas Consider pap smear on follow up of older
  • 22. Forensic Collection for DNA • Compromises
  • 23. What can we do to help these kids?
  • 24. Essential Elements of Trauma-Informed Child Welfare Practice (adapted from Rady Children’s San Diego) 1. Safe 2. Assist in reducing overwhelming emotion 3 . Help children make new meaning of their trauma history and current experiences • Support positive relationships in their life • Provide support and guidance to child’s family and caregivers • Address the impact of trauma on child’s behaviour, development, and relationships 4. Coordinate services with other agencies.