Multiagency Guidance for the Response to Presentations of Genital Symptoms in Children including where there are Concerns of Sexual Assault

Children commonly have medical issues regarding their genitalia. Often a presentation can create a concern that there has been a sexual assault.

It is important to manage these cases in a systematic way so as to provide best care to children with responsive medical care and a balanced safeguarding response.

There are three competing facts that can make decision making in these scenarios complicated.

1. Children who are being sexually abused do not necessarily present with physical symptoms;
2. Children who are abused can present with genital symptoms;
3. Children with genital symptoms are not necessarily being sexually abused.

The aim of this guidance is to provide the best next steps for each agency so as to balance the response in light of these facts taking into account the role of the individual in assessing the child.

All people working with children may meet a situation where concerns are raised but not all people working with children have the expertise to differentiate non-abusive from abusive presentations.

This causes difficulties in two main ways:

1. A safeguarding issue is not raised due to the person not knowing there should be a concern;
2. A safeguarding issue is assumed by a person who feels they are unable to say there is not a concern.

Below are two pathways to support decision making: They are guidance and not exhaustive, however if you feel the guidance doesn’t fit with the scenario you are facing then discussion with your immediate safeguarding lead is recommended. This guidance is to replace the previous genital symptoms pathway for General Practice and co-ordinate a response to related presentations in any environment.

The guidance has two pathways:

If it is within your role to medically assess children, both Pathways apply to you.

If it is not within your role to medically assess children only Pathway 1 applies.

Pathway 1

Pathway 2

1. History of Domestic Violence;
2. Substance abuse;
3. Parental mental health concerns;
4. The child is on a Child Protection or Child in Need plan:

If you are aware the child is already open to CSC and you do not have new concerns that they are suffering or have suffered significant harm through sexual abuse, or been subjected to FGM, then ask consent from the family to inform their social worker of interaction.

If you have new concerns that they are suffering or have suffered significant harm through sexual abuse, or been subjected to FGM then document your concerns and make a referral as per Referrals Procedure and Child Protection Enquiries - Section 47 Children Act 1989 Procedure.

Even if the child /YP is already open to CSC you should expect a new strategy meeting and response in line with the Child Protection Enquiries - Section 47 Children Act 1989 Procedure.

• Disclosure of abuse.
• Other suspicious non ano-genital injuries.
  • Where you have reason to suspect that a young person is in a sexual relationship which is abusive including a sexually active relationship under 18 years of age with an individual in a position of trust or a family member as per Sexual Offences Act 2003, or if the child is under 13 years Please see safeguarding guidance ‘Underage sexual activity’ for more information, unless the young person was in a consensual and non-abusive relationship with no evidence of coercion and aged over 16 at the time of conception. If under 16 at the time of conception unlawful sexual activity has taken place, we recommend discussing with your safeguarding lead and documenting clearly why abuse is not suspected if a referral is not made to social care..
• Parent / carer concern regarding CSA if you cannot categorically state abuse has not occurred;
• Proven sexually transmitted infection (STI). (If an STI is suspected do not perform investigations but refer as per pathway 2 as testing will be performed as part of forensic examination.);
• Sexualised behaviour inappropriate to stage of development. Please see safeguarding guidance ‘Harmful Sexual Behaviour’

Note about Harmful Sexual Behaviours

Children are exploratory and at different ages explore in different ways. If a child is exploring their body and are responding to that exploration with age appropriate responses, age appropriate repetition and age appropriate interest then their behaviour is unlikely to be harmful.

Insertions:

The insertion of an item into an orifice is not an uncommon childhood activity. If it is the first time this has occurred, the item is readily available, would commonly be found in other orifices (marbles, M&M’s etc.) and relatively easy to insert then the event is less likely to be associated with abuse. That may still mean that a review of the child’s social circumstances is needed and a discussion with a SARC consultant may be helpful especially if active removal is needed. Each insertion event will have its unique picture and can be complicated but most families accept that if an item has been inserted discussions are generally had.

Repeated insertions, more complicated or sexually associated items, inappropriate actions associated with insertion (recording or presenting) or additional harmful sexual behaviours would raise further concerns.

Consent to make a referral is not required where there is concern that the child or young person is at or has suffered significant harm but it is best practice for professionals to be open and honest with the family, child and young person regarding your concerns and necessary actions unless in doing so you believe you would:

• Place a person (the individual, family member, worker or a third party) at increased risk of significant harm (if a child), or serious harm (if an adult);
• Prejudice the prevention, detection or prosecution of a serious crime- this is likely to cover most criminal offences relating to children. (This may be particularly relevant in sexual abuse where the suspected perpetrator(s) may be informed in the case of suspected CSA in the family environment);
• Lead to an unjustified delay in making enquiries about allegations of significant harm (to a child), or serious harm (to an adult).

A 16-17 year old should be assumed to have capacity unless it is established that they lack consent. In many cases they can therefore provide their own consent and can request family are not informed.

In the rare situation where the CYP is 16-17 year old at the time of the abuse/assault and they have capacity they may not consent to have social care or the police involved, and their wishes should be respected but legally this is an offence against a child and requires a referral to CSC and the police for further exploration and investigation. This is often a challenging situation for all involved parties and it is advised that guidance is sought from your safeguarding lead / legal team in this instance.