Dr Rosemary Isaacs

FRACGP MForensMed (Monash) Medical Director Sexual Assault and Clinical Forensic Medicine

RPA and Liverpool Hospitals

rosemary.Isaacs@sswahs.nsw.gov.au

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.