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.
