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Equipping the Expert Witness for Cases of Suspected Child Sexual Abuse

Medico Legal

by Dr Geoff Debelle, Officer for Child Protection, Royal College of Paediatrics and Child Health


The 4th Edition of “The Physical Signs of Child Sexual Abuse: an evidence-based review of guidance for best practice” (often referred to as the “Purple Book”) was launched at the offices of the Royal College of Paediatrics and Child Health (RCPCH) on 20th May 2015. The first edition was published by the Royal College of Physicians in 1991, in the wake of the Cleveland Inquiry that recommended the medical profession agree a consistent vocabulary to describe physical findings
that may be associated with child sexual abuse and to seek to understand the natural history and significance of such signs. This was updated in 1997. Following the growing recognition of the importance of evidence-based medicine, the 1997 edition of the RCP book was revised in line with the research evidence with The Physical Signs of Child Sexual Abuse: An evidence-based review and  guidance for best practice published in March 2008 by the RCPCH.

This latest edition of “the Purple Book” – it has retained its distinctive purple colour – is the result of a full evidence-based review. There is a chapter devoted to each key category of sign that, after defining the relevant anatomy, provides an evidence- based review and analysis and then identifies key issues for clinical practice, based on the evidence statements. It covers additional areas to support decision making around suspected child sexual abuse including healing of anogenital injuries, genital bleeding in pre-pubertal girls, and anogenital signs of accidental injuries in girls and boys, which are all critical areas to support
evidence-based legal practice.

The evidence statements are the result of a substantial collaboration between the RCPCH, the Faculties of Forensic and Legal Medicine and Genitourinary Medicine of the RCP and the American Academy of Pediatrics (AAP). It represents a huge effort and is a work of great scholarship. It is the collaboration with AAP that is so important and truly groundbreaking. This edition has gone to print with substantial agreement on all the evidence statements and clinical practice
issues from experts in the field from both sides of the Atlantic. The security of the available evidence inherent in such agreement should obviate the apparent need for independent experts from outside the UK to be instructed on a case of suspected child sexual abuse within a UK jurisdiction. This is to be welcomed.

The section on the extent of anogenital signs is particularly useful from a medico-legal context, as it draws attention to the lack of residual signs of penetrative abuse in a high proportion of cases of suspected child sexual abuse. Thus, it is important that child protection agencies, including the Police, and legal experts continue to assess and, indeed prosecute a case of suspected child sexual abuse on the basis of a reliable testimony from the child, despite the absence of so-called corroborative physical evidence. The chapter provides the evidential power for such a conclusion. Many practitioners have seen cases of suspected child
sexual abuse dropped because of lack of corroborative physical signs. This must change and this chapter provides the evidence for such change.

In his wise and generous foreword to this edition, His Honour Lord Justice McFarlane draws attention to the “tone” of the advice, evident on every page. By this he meant that the evidence statements were not overstated or dogmatic but steered a reliable course between signs of non-abuse to abuse. He makes the point that this book is ‘not intended to be a guideline for the diagnosis of child sexual abuse’; rather it has been developed as an aid to clinical decision-making. At the end of the day, the professionals involved draw on their expertise and experience, weighing up the particular aspects of the case with the evidence available to come to a reasonable conclusion that will be in the best interests of the child, the family and justice.

The RCPCH prepares paediatricians to take on the expert witness role, by providing the appropriate knowledge, skills and support they need to identify and articulate key clinical indicators of sexual abuse to signal or differentiate physical signs from other conditions and, ultimately, to better protect infants, children and young people across the UK.

The RCPCH deliver an annual training course for paediatricians, in partnership with Bond Solon, to develop excellence in child protection expert witness work. For information about this course, or to purchase a copy of ‘The Physical Signs of Child Sexual Abuse’ please see www.rcpch.ac.uk/physical-signs-child-sexual-abuse.

Physical signs of child sexual abuse - 2015
This evidence-based review and guidance for best practice is a revision of the 2008 Royal College of Paediatrics and Child Health (RCPCH) publication 'The Physical Signs of Child Sexual Abuse’.

Based on the best available evidence, it has been produced in collaboration with the American Academy of Pediatrics (AAP), the Royal College of Physicians of London (RCP) and The Faculty of Forensic and Legal Medicine (FFLM)

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