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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 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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Dr Rosemary Isaacs
FRACGP MForensMed (Monash) Medical Director Sexual Assault and Clinical Forensic Medicine
RPA and Liverpool Hospitals
Adolescent SA
Teenage presentations: What are the issues
• Engaging the adolescent
• Family and support
• Adolescent genital examination
for girls and boys
• Promoting safety in adolescents
What age is adolescence?
• Physical: Pubertal Development
• Mental, Emotional and Social
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
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
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
Josie aged 16, yr 11
• Out somewhere she is not meant to be
• Raped
• Goes to police herself
• Comes to hospital, alone
• What can you do to help these teenagers
– feel safe
– co-operate with the examination
– Recover
– ?
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
• Assist them to evaluate
• Is there anyone they can turn too
• Reasons they don’t wan to tell their
Mum/aunt/older sister/counsellor
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.
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
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
Adolescent genitalia
Adolescent genitalia
Possible speculum use
• Small or extra small speculum with a good light source
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
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')
Boys… the anus
• Genitals: record injury
• Medical opinion for
Penile or scrotal injury or pain
Images removed
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
Forensic Collection for DNA
• Compromises
What can we do to help these kids?
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.