Health Needs of Sexually Exploited Children

Lindsay Groves Nicola Robinson Sarah Staveley

November 2013

Objectives of session

To understand the range and complexities of health needs

What we actually do

Recognise opportunities to identify and prevent / intervene in cases of CSE

CASE STUDY

Jane 14 years: history

Born in North England Antenatal and birth history normal Congenital Dislocation of hips surgery No other health problems

history cont.
Moved to North Wales aged 12 years Had not attended school for previous year. Reason givenhip pain Visited GP with her father for emergency contraception (morning after pill) aged 14 years

Jane :Social History

Child protection concerns in England Father a paedophile Left the family when Jane was 6 years Harry moved in following year and has been with family ever since Family consists mother (mental health problems), stepfather (Harry), brother aged 18 years (learning difficulties) and Jane

Referral

Numerous referrals to police by members of the public. Seen young girl and adult male in a car parked at the beach late on Summer evenings . Jane got into cars with various other adult males. All referrals suspected sexual activity were taking place.

Section 47 investigation
Police were told they were out enjoying the summer sunsets Jane wearing inappropriate clothing Denied anything untoward Excuse given for non-attendance at school was bullying and hip pain

Child Protection Case Conference

Attended by mother , brother and Jane. Jane angry that her stepfather had been accused. Claimed he was a kind and wonderful father and had done nothing wrong. Mother and brother silent. Janes name placed on Child Protection Register.

Investigation cont.

Police seized videos, DVDs, computers and mobile phones

Found >2000 sexual images of children

Stepfather remanded

Investigation cont.

Videos found showing Jane having sexual intercourse with 50 different males Mother involved in some of the videos and DVDs. Appeared to be semi-conscious. Jane disclosed 17 men prosecuted Most have now served their prison sentences and are back in the community

Management
Mother, brother and Jane moved out of the area Jane attended an alternative education provision Joint visit GUM clinic. Examined and investigations taken for sexually transmitted infections. Negative

Outcome

Harry sentenced to 15 years in prison

Subsequently found to have murdered a previous partner

Now serving life imprisonment

So what about Jane?

How do you think she may have presented?

vigniette

Janes presentation
Controlling Confident Chatty Defensive Angry Assertive

What are the issues for Jane?

What are the issues for Jane?

Mental health issues Safety issues for Jane and her family Safety issues for Janes peers Sexual health Ongoing investigation / statements / interviews as more of the perpetrators are found Perpetrators now back in the community Peer relationships Education

Mental Health Issues

2/3 of sexually abused children develop psychological symptoms. There are no specific syndrome with a clearly defined cluster of behavioural difficulties that are unique to those who have experienced CSA. Misconceptions about normal sexual behaviour and morality to the child. Sexual arousal may come to be associated with rewards, receiving care, love and attention and display sexualised behaviour. Perpetrators blames, denigrates and/or coerces the child into maintaining secrecy. Disclosure can lead to developing beliefs about the self as damaged goods, which can be a contributing factor to self-harm, suicide, and other selfdestructive behaviours The childs trust in perpetrator are violated and the expectation that other adults will be protective is not met. This leads to beliefs of others as not trustworthy. This can give rise to a variety of relationship problems, intense sadness, anger, and delinquency. Powerlessness: Can lead to beliefs about generalized personal ineffectiveness and can lead to develop identity as a victim. Interpersonal Difficulties: Within other relationships the young person will often transfer sexual, aggressive/controlling or anxiety-related feelings from the abusive situation to another individual and there could present as fearful, aggressive/controlling, or seductive

Janes Mental Health Presentation

Jane was referred to the local CAMHS service by the therapeutic team in Social Services. The primary focus of that input was to come to terms with CSE. A mental health assessment indicated that Jane was displaying a variety of mental health difficulties. Post Traumatic Stress Disorder: Frequent flashbacks, hearing his voice, hypervigilant to those around her. Depression: poor sleep and appetite, tearfulness, low self-esteem Self harm/Suicidal: Is most often an attempt to cope with intense and painful emotions. Jane often reported hearing the voice of her stepfather telling her to cut herself. Frequent and recurrent ideas about taking an overdose and dreaming about ending it. Interpersonal difficulties: Sharing inappropriate information with friends or make threats of self-harm in a coercive way. Reported feeling excluded and victimised by friends. Generally Jane flitted between victim and being in control (reported to be domineering and controlling in the family home). Often trigger to angry outbursts was having restrictions/demands put on her.

Therapeutic intervention
Janes therapeutic intervention with CAMHS involved;

Safety planning: Jane, her mother, social services therapist, and CAMHS therapist were involved in devising a safety plan. Difficult at times as Jane would not commit/promise to maintain safety, would not accept information about help-lines etc. Dialectical Behaviour Therapy (DBT) was offered to Jane as it was felt to be the most suitable first line intervention. DBT was specifically developed to target self-harm and suicidal behaviours. DBT encourages individuals to accept and cope with negative mood states without resorting to self-harm or other maladaptive behaviours. DBT involves; 1. Individual therapy 2. Group psycho-educational component 3. Strategies to help generalise new skills to daily life (e.g. telephone/text out of hours) 4. Therapist consultation meeting. Jane was referred for DBT but declined.

Therapeutic Intervention 2

Medication: Jane met with CAMHS Psychiatrist who prescribed Jane medication to target symptoms of anxiety and depression. Barriers: A number of barriers were thought to influence Janes engagement with CAMHS including; 1. Her sense of safety (e.g. proximity of perpetrators), 2. Ongoing investigations pertaining to stepfathers ex partner 3. Anniversary of confession 4. Inherent difficulties in developing new relationships and ending of existing ones 5. Mums ability to contain and protect Jane. Consultation: A large part of CAMHS involvement involved attending multi-agency meetings, sharing our understanding of Janes presentation and making suggestions/recommendations on how those around her could help contain her and keep her safe.

Medical examination in sexual abuse

Examination
A clear statement by the child is the single most important factor in making a diagnosis of sexual abuse A diagnosis of sexual abuse should rarely, if ever be made on physical signs alone

Examination cont.
A substantial proportion of sexually abused children have no abnormal physical signs. The proportion varies with the types of abuse and, most importantly, the time which has elapsed since the most abusive episode Absence of such signs does not imply absence of abuse.

Consent

Informed consent must always be obtained from the child or young person and the carer with PR

Consent
Jane consented to sexual intercourse with all the men Told she was pretty Told she had a lovely singing voice and should be a pop star

consent

if you cannot say NO then saying YES is meaningless

Medical examination in sexual abuse

When?
Depends on likelihood of forensic evidence Most convenient for child

Where?
SARC Hospital

Who?
forensically trained paediatrician

Why?

Examination
History Examination Forensic samples Investigations Treatment Follow up

June 2013

Scientific examination
Locards

Principle-

Every contact leaves a trace

Forensic Overview
Time Limits
7 days Vaginal rape 3 days Anal rape 2 days Oral rape 2 days Sucking or biting 12 hrs Digital penetration 3 days Under 13 s Toxicology and clothing

Chronic

Acute

Can be up to months e.g. hymenal injuries

Forensic Overview
Time Limits
7 days Vaginal rape 3 days Anal rape 2 days Oral rape 2 days Sucking or biting 12 hrs Digital penetration 3 days Under 13 s Toxicology and clothing

Content
Statement Top-to-toe exam Injuries documented Forensic + toxicology samples collected Evidence sent to Forensic Science Service for analysis Take statement Extent of examination determined by history Any injuries documented

Chronic

Acute

Can be up to months e.g. hymenal injuries

Sexual Health Issues

Contraception
Sexually Transmitted Infections
? Chain of evidence Window period

PEPSE risk assessment

Could we have prevented the abuse?

Could we have prevented the abuse?

? Referral made by FP clinic ? Referral made by school ? Could GP have picked up any signs?

Might have prevented the 9 months of abuse by 50 men ?

Everybodys business
Awareness of CSE Awareness of Vulnerabilities Familiarity with SERAF Discussion with colleagues Familiarity with child protection procedures Multiagency partnership working

Moderate Risk Indicators

Missing / staying out Mobile phone - use that causes concern Multiple callers Expression of despair self harm Exclusion / disengaging from school STIS / Pregnancy / TOP Drug & Alcohol misuse Internet use that causes concern

Significant Risk Indicators

Disclosure sexual or physical assault Peers involved in CSE Older BF / Controlling adult Physical or emotional abuse by controlling adult Unexplained money / clothing / items Frequenting areas known for CSE

What is happening BCUHB ?

CSE Task and Finish Group implementing SERAF, training, crib cards Multiagency CSE/MFH groups across N Wales MASH pilot (multiagency safeguarding hub)

Questions Discussion

THANKS FOR LISTENING