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BMJ No 7124 Volume 316 Education and debate Saturday 3 January 1998
Ethical debateChild sexual abuse: when a doctor's duty to report abuse conflicts with a duty of confidentiality to the victim Social services can act on anonymous information about abuseJane Wynne
The link between physical and sexual abuse was not well recognised 15 years ago. It is now known that about one sixth of physically abused children have also been sexually abused.(1) When this child was admitted to hospital for investigation, had she been referred because of her parents' or general practitioner's concern? The admission gave staff an opportunity to observe her behaviour and her attachment to her parents. Why hadn't her parents noticed she was upset? Did she talk to the nurses? Did she have any genital symptoms such as soreness or dysuria? Did anyone ask the child why she had so many bruises? Probably not in 1980, but all these questions spring to mind in 1997. In 1997 there is a greater awareness of the various ways in which
sexual abuse may present, and children are more likely to be spoken to
and treated as people rather than "objects of
concern."(2-4) Paediatricians are also more likely to be
direct with parents. But even today most sexual abuse goes
unrecognised. Even in proved cases of sexual abuse in children similar
to the one described above, neither the general practitioner nor school
(or school nurse) is likely to have voiced concern, and these families
are not known to the National Society for the Prevention of Cruelty to
C Why were there no more bruises? Paedophiles are likely to continue to
abuse, but perhaps the parents knew more than they had volunteered? Had
the parents challenged the babysitter? Would this distressed young
woman be able to talk to her parents now? If they were aware or
suspicious of sexual abuse all those years ago, they might be able to
help their daughter understand her abuse even at this late stage,
unless they were in some way involved.
What should the paediatrician do with this new information? In
particular, what is his or her responsibility towards the
"babysitter's" children?
The General Medical Council gave the following advice in 1993: "Where
a doctor believes that a patient may be the victim of abuse or neglect
the patient's interests are paramount and will usually require a
d The police cannot investigate unless the young woman is able to
make a complaint, but the social se Whatever happens, the young women clearly needs help and with skilled
therapy may learn to live with the knowledge of her childhood abuse
more comfortably. If the allegations are unfounded, preliminary
investigations will be negative and the former babysitter's family
will be undisturbed. Or might this be a repetition of the original
mismanagement?
Community Child Health,
email: jladley@ulth.northy.nhs.uk
References
1 Hobbs C J, Wynne J M. The sexually abused battered child.
Arch Dis Child 1990;65:423-7
2 Department of Health and Social Security. Diagnosis of
child sexual abuse: guidance for doctors. London: HMSO, 1988.
3 Hobbs C J, Wynne J M. Clinical aspects of sexual abuse. In:
Child abuse and neglect, a clinician's handbook.
London: Churchill Livingstone, 1993:139-94.
4 Butler-Sloss E. Report of the inquiry into child abuse
in Cleveland. London: HMSO, 1987.
5 General Medical Council. Duties of a doctor
(confidentiality). London: G
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