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SERVICES FOR THE MENTALLY HANDICAPPED
1100 EXAMINATION OF THE ANUS IN SUSPECTED CHILD SEXUAL ABUSE
SiR,—I read with increasing concern the article by Dr Hobbs and Dr Wynne on child sexual abuse (Oct 4, p 792). Hobbs and Wynne make assumptions that are not justified by the evidence presented. Their findings are based on inspection only, and this is inadequate to assess the tone of the anal sphincter and the extent of any damage to the anal canal. They do not do a more thorough examination because this might distress the child-yet they are prepared to come to conclusions which will have devastating effects on the future well-being of the child and its family. Many of the histories given are very vague. Children of all ages may refer to their "bottom" or "bum" when they mean any part of their genitalia, and even older children’s knowledge of their anatomy may be very inadequate. Without a more thorough investigation it is not possible even to be sure what is being alleged. At least 4, and possibly 6, of the 15 photographs could well be within normal limits. It is very easy to pull on the buttocks and produce photographs which show apparent fissures and slackness of the sphincter. In 5 cases they refer to reddening of the anus and perianal skin. Many of the children we see where sexual abuse is alleged are poorly looked after, so any finding of redness is of little value. Reflex dilatation and "anal twitchiness" are not confined to sexually abused children. Hobbs and Wynne state that many of the signs are "dynamic, changing as the observer watches and with time after abuse", yet they do not state the time interval between the alleged abuse and the taking of photographs. If the findings they describe as fissures are abnormal they must be due to previous tears and are likely to leave more long-lasting evidence of injury. What was the incidence of skin tags in these children? These are often caused by healing of haematomas and may be highly significant. As a police surgeon in Manchester I have examined hundreds of children in whom sexual abuse has been alleged. I always make a thorough examination of the child, including the genitalia and anus. In 63 girls and 5 boys seen in 1985,I found definite evidence of anal interference in only 2 girls and 2 boys. Of 98 girls and 7 boys seen in 1986, there was a history of anal interference in 14 girls and 7 boys but evidence for it in only 6 girls and in none of the boys. Increasing interest in child sexual abuse and the great difficulties in finding evidence to corroborate the child’s story cause great anxiety to those who are trying to help these children. Nonetheless a judgment based on inadequate evidence cannot be helpful. 459 Altrincham Road, Manchester M23 8AA
RAINE E. I. ROBERTS
series; were they believed? Research shows that children rarely lie or fantasise about sexual abuse. We are willing to give more details of any of the cases we presented; indeed Roberts heard more at a lecture given by J. M. W. in September, 1986, at Leeds University, without comment. More research is needed; we are just beginning, but have examined almost 500 children this year. Anal tone is a difficult sign to assess, and manometry is not an easy technique, especially in young children. Fissures, scars, skin tags-what is their incidence? Some signs regress or even disappear when the abuse ceases and these include reflex dilatation, gaping anus, twitchiness, fissures, and bruising. We build a diagnosis on history, including the use of anatomically correct dolls, and on physical examination and bacteriological and forensic tests. We follow up our cases and observe healing. Perpetrators may admit to the abuse, and in our published series several of the abusers have been convicted. We do not make a diagnosis on clinical photographs alone. If 7 (or 9) of our photographs are accepted as not normal, what about the other 6 (or 4)? Perhaps we should ask, given the history, what is the proof that there is normality? Clarendon Wing, General Infirmary Leeds LS2 9NS
at
Leeds,
JANE M. WYNNE CHRIS HOBBS
1. Roberts REI. Sexual offences. In: McLay WDS, ed. The Association of Police Surgeons of Great Britain, 1985.
new
police
surgeon.
SERVICES FOR THE MENTALLY HANDICAPPED p
Sip,—We would question whether Dr Kinnell’s view (Oct 4, 815) is generally applicable to a service which varies greatly from
one
district to the next.
Handicap is often multiple, especially where it is severe, and may include physical and perceptual components beside cognitive, social, and psychiatric problems. For people with handicaps to grow up as normally as possible a broad-based range of supportive services is essential. This is the special remit of the community mental handicap team: most people with mental handicap live out of hospital. At what point such problems as sleep disturbance, incontinence, and communication difficulties come to be seen "psychiatric" will depend on local services and relationships much as
as as
the beholder. Certainly the less common, more specialised form of disorder, whether psychiatric, orthopaedic, or other, will require a treatment service. Traditionally provided from a hospital base, the work will often be within the community. Clinics can be held at school and training centres in conjunction with members of the community on
team.
** This letter has been shown to Dr Wynne and Dr Hobbs, whose reply follows.-ED.L. SiR,--Our paper illustrates the variety of physical signs seen in anally abused children. The children we see differ in important ways from those in Dr Roberts’ series. Ours are younger, average age 7l years, with one-third 5 years or less. We see a higher proportion of boys (1 boy for every 2 girls). Presentation varies: 20 % disclose anal abuse, 25 % are associated with non-accidental injury, 20% have symptoms (eg, discharge), and 20 % have behaviour problems, and in the rest the presentation is via a sibling, other relative, or friend of the abused child. Children presenting at police stations are making a complaint. Roberts’ figures published in 1985 were that only 4/43 of rape victims were 11years or under. In a 4-year period 195 children under 16 years were seen; 13 had "general injuries" and 95 "genital injuries or evidence of abuse". None was recorded as having anal injury. In the 1985 series there were few boys, but 4/68 children had signs of anal abuse. In 1986, 21 out of 105 children gave a history of anal abuse, however. Clearly many practitioners, ourselves included, have failed to examine the anus adequately until recently. We had also expected florid signs after anal abuse but our photographs show that a variety of signs are compatible with anal abuse. We are also concerned about the 21 children who have a history of anal abuse in Roberts’
For a close and comprehensive link between these two services it is essential that a doctor be one of the central members of the community mental handicap team. In Newcastle the medical member is a senior clinical medical officer who is also an honorary senior registrar on the regional training scheme in community paediatrics. This rotational scheme includes training in child psychiatry and the psychiatry of mental handicap, as well as in other areas such as orthopaedics and neurology. This leaves him suitably trained and placed to identify the patients needing specialist (including psychiatric) referral. A similar specialist is needed for the adult side of the service. The need to increase the knowledge and skills of general practitioners, community health doctors, and paediatricians in the special problems of the mentally handicapped is recognised in special courses and training that are organised in the
region. Lack of money is a problem that faces us all, but matters will not be improved by the perpetuation of hospital versus community rivalries. Through commitment by all parties to provide adequate training and recognise each others’ special knowledge, it is possible to achieve the correct professional relationships to provide for the health and welfare of this group of people. Community Mental Handicap Team, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE
P. M. JONES
Prudhoe Hospital
T. P. BERNEY
SiR,—I read with increasing concern the article by Dr Hobbs and Dr Wynne on child sexual abuse (Oct 4, p 792). Hobbs and Wynne make assumptions that are not justified by the evidence presented. Their findings are based on inspection only, and this is inadequate to assess the tone of the anal sphincter and the extent of any damage to the anal canal. They do not do a more thorough examination because this might distress the child-yet they are prepared to come to conclusions which will have devastating effects on the future well-being of the child and its family. Many of the histories given are very vague. Children of all ages may refer to their "bottom" or "bum" when they mean any part of their genitalia, and even older children’s knowledge of their anatomy may be very inadequate. Without a more thorough investigation it is not possible even to be sure what is being alleged. At least 4, and possibly 6, of the 15 photographs could well be within normal limits. It is very easy to pull on the buttocks and produce photographs which show apparent fissures and slackness of the sphincter. In 5 cases they refer to reddening of the anus and perianal skin. Many of the children we see where sexual abuse is alleged are poorly looked after, so any finding of redness is of little value. Reflex dilatation and "anal twitchiness" are not confined to sexually abused children. Hobbs and Wynne state that many of the signs are "dynamic, changing as the observer watches and with time after abuse", yet they do not state the time interval between the alleged abuse and the taking of photographs. If the findings they describe as fissures are abnormal they must be due to previous tears and are likely to leave more long-lasting evidence of injury. What was the incidence of skin tags in these children? These are often caused by healing of haematomas and may be highly significant. As a police surgeon in Manchester I have examined hundreds of children in whom sexual abuse has been alleged. I always make a thorough examination of the child, including the genitalia and anus. In 63 girls and 5 boys seen in 1985,I found definite evidence of anal interference in only 2 girls and 2 boys. Of 98 girls and 7 boys seen in 1986, there was a history of anal interference in 14 girls and 7 boys but evidence for it in only 6 girls and in none of the boys. Increasing interest in child sexual abuse and the great difficulties in finding evidence to corroborate the child’s story cause great anxiety to those who are trying to help these children. Nonetheless a judgment based on inadequate evidence cannot be helpful. 459 Altrincham Road, Manchester M23 8AA
RAINE E. I. ROBERTS
series; were they believed? Research shows that children rarely lie or fantasise about sexual abuse. We are willing to give more details of any of the cases we presented; indeed Roberts heard more at a lecture given by J. M. W. in September, 1986, at Leeds University, without comment. More research is needed; we are just beginning, but have examined almost 500 children this year. Anal tone is a difficult sign to assess, and manometry is not an easy technique, especially in young children. Fissures, scars, skin tags-what is their incidence? Some signs regress or even disappear when the abuse ceases and these include reflex dilatation, gaping anus, twitchiness, fissures, and bruising. We build a diagnosis on history, including the use of anatomically correct dolls, and on physical examination and bacteriological and forensic tests. We follow up our cases and observe healing. Perpetrators may admit to the abuse, and in our published series several of the abusers have been convicted. We do not make a diagnosis on clinical photographs alone. If 7 (or 9) of our photographs are accepted as not normal, what about the other 6 (or 4)? Perhaps we should ask, given the history, what is the proof that there is normality? Clarendon Wing, General Infirmary Leeds LS2 9NS
at
Leeds,
JANE M. WYNNE CHRIS HOBBS
1. Roberts REI. Sexual offences. In: McLay WDS, ed. The Association of Police Surgeons of Great Britain, 1985.
new
police
surgeon.
SERVICES FOR THE MENTALLY HANDICAPPED p
Sip,—We would question whether Dr Kinnell’s view (Oct 4, 815) is generally applicable to a service which varies greatly from
one
district to the next.
Handicap is often multiple, especially where it is severe, and may include physical and perceptual components beside cognitive, social, and psychiatric problems. For people with handicaps to grow up as normally as possible a broad-based range of supportive services is essential. This is the special remit of the community mental handicap team: most people with mental handicap live out of hospital. At what point such problems as sleep disturbance, incontinence, and communication difficulties come to be seen "psychiatric" will depend on local services and relationships much as
as as
the beholder. Certainly the less common, more specialised form of disorder, whether psychiatric, orthopaedic, or other, will require a treatment service. Traditionally provided from a hospital base, the work will often be within the community. Clinics can be held at school and training centres in conjunction with members of the community on
team.
** This letter has been shown to Dr Wynne and Dr Hobbs, whose reply follows.-ED.L. SiR,--Our paper illustrates the variety of physical signs seen in anally abused children. The children we see differ in important ways from those in Dr Roberts’ series. Ours are younger, average age 7l years, with one-third 5 years or less. We see a higher proportion of boys (1 boy for every 2 girls). Presentation varies: 20 % disclose anal abuse, 25 % are associated with non-accidental injury, 20% have symptoms (eg, discharge), and 20 % have behaviour problems, and in the rest the presentation is via a sibling, other relative, or friend of the abused child. Children presenting at police stations are making a complaint. Roberts’ figures published in 1985 were that only 4/43 of rape victims were 11years or under. In a 4-year period 195 children under 16 years were seen; 13 had "general injuries" and 95 "genital injuries or evidence of abuse". None was recorded as having anal injury. In the 1985 series there were few boys, but 4/68 children had signs of anal abuse. In 1986, 21 out of 105 children gave a history of anal abuse, however. Clearly many practitioners, ourselves included, have failed to examine the anus adequately until recently. We had also expected florid signs after anal abuse but our photographs show that a variety of signs are compatible with anal abuse. We are also concerned about the 21 children who have a history of anal abuse in Roberts’
For a close and comprehensive link between these two services it is essential that a doctor be one of the central members of the community mental handicap team. In Newcastle the medical member is a senior clinical medical officer who is also an honorary senior registrar on the regional training scheme in community paediatrics. This rotational scheme includes training in child psychiatry and the psychiatry of mental handicap, as well as in other areas such as orthopaedics and neurology. This leaves him suitably trained and placed to identify the patients needing specialist (including psychiatric) referral. A similar specialist is needed for the adult side of the service. The need to increase the knowledge and skills of general practitioners, community health doctors, and paediatricians in the special problems of the mentally handicapped is recognised in special courses and training that are organised in the
region. Lack of money is a problem that faces us all, but matters will not be improved by the perpetuation of hospital versus community rivalries. Through commitment by all parties to provide adequate training and recognise each others’ special knowledge, it is possible to achieve the correct professional relationships to provide for the health and welfare of this group of people. Community Mental Handicap Team, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE
P. M. JONES
Prudhoe Hospital
T. P. BERNEY