ADOLESCENTS & THE LAW

(Sexual Abuse )

Dr Sheila Marimuthu
Consultant Paediatrician & Adolescent Specialist
HKL

Case 1
14

yr old girl

Comes

with friend- to check UPT

Case 2
15

yr old,
Presents to Social Welfare Services
Pregnant
Disowned

CASE 3
16

yr

Single
Just

mum

delivered at Labour room/ post natal

ward

CASE 4
16

yr Boy

Sypillis
?

Homosexual tendency

Cases at AMU
no
466

500
386

400

351

273

300

no

200
100

68

0
Oct-Dec 03 Jan-Dec 04 Jan-Dec 05 Jan-Dec06 Jan-Dec07

Sexual Abuse
250
200
150
nos
100
50
0

220
171
113

97

32

Series1

Oct- Jan- Jan- Jan- JanDec03 Dec04 Dec05 Dec06 Dec07

yr

Presentations
Consented Sexually

<16 yrs

assaulted

Influence

of Drugs & Drinks

Teachers

/JKM /Police

Child Sexual Abuse

Examination
Triage immediately
Provide private room
Contact OSCC or OG (SCAN team)

Obtain consent from police, parent/guardian, JKM.

Police or welfare report for known or suspected abuse

< 72 hours post-assault

with injury:
Examine immediately
in emergency room

< 72 hours post-assault

without severe injury:
Examine immediately
in appropriate clinic

>72 hours post-assault:

Examine as soon as
convenient in
appropriate clinic/ ward

Role of police

Provide immediate protection to child

Investigation of offences and when, appropriate,
prosecution of offender

Role of Child Protector

Investigation and assessment of whether child is in

need of care and protection
Ensure protection of child in placement of child
Assist in rehabilitation of child and family

Medical Diagnosis of Sexual

Abuse
Does

not primarily aim at proving the abuse

It must never be the exclusive diagnostic
procedure
This is because of the frequency of normal
findings in victims of CSA

Why are normal physical

findings so frequent?
Frequency of positive findings mainly
depends on:
type of abuse
if anogenital tissues are involved at all
the degree of force used
timing of the examination
elasticity of the hymen

Clinical assessment

Establishing a relationship of trust

Focussing on concerns, feelings and

behaviour

Determining the degree of risk

Conducting a thorough and thoughtful

physical examination

The medical interview

An effective medical interview not only

collects information, but also sets the tone
for future interactions
Mackenzie, 1991

Presentations
Consented Sexually

<16 yrs

assaulted

Influence

of Drugs & Drinks

Teachers

/JKM /Police

Clinical assessment
Supporting

the young persons own

decision making

Providing

developmentally appropriate
health education

Knowing

about adolescent resources and

when to refer

Establishing a relationship of trust

Adolescents

are usually nervous about seeing

doctors and sensitive to the way office staff and
physicians deal with them

To foster

the relationship between the physician and

the teenager, it is important that the teenager be seen
without the parent for all or part of the visit

Opening gambits

Invite the adolescent to see you alone

Define the basis of confidentiality

Respond to the adolescents reactions

Clarify the reasons for the consultation

Explore the chief complaint

Attitude and demeanor

Be

yourself while maintaining a professional

manner

Be
Be

relaxed, open, flexible and unhurried

warm, sincere and non judgemental

without condoning risky behaviour

Confidentiality

If you go to a local doctor, you feel

everyone would find out

I dont know any doctors I can trust

I hate talking about embarrassing

problems

Confidentiality - principles

The most important quality of an adolescents

relationship with a health professional

Involves respect for privacy and recognition of

capacity for rational choice & informed consent

Supports the protection and promotion of health

Occurs in the context of flexibly proffered

guidance and adult (including parental/family)
support

A form of words
Anything we discuss will be kept confidential.
That means I will not repeat anything you tell
me to anyone else, unless I think it would help
you and you give me permission to do so.
There are some situations where I will not be
able to keep confidentiality
Kang, 1999

A form of words
I will not be able to keep confidentiality:

if I am concerned that you could harm yourself or someone

else
if I am concerned that you are being harmed or at risk of
being harmed because of somebody else

In these situations it would be my duty to ensure

that you are safe. I would tell you if I need to
notify somebody about something youve told me
and I would make sure that you have as much
support as possible.
Kang, 1999

Interview tips
Be

interactive rather than interrogative

Listen

and provide non-verbal support

Check

language if unsure of meaning

Answer

questions simply and honestly

Interview tips

Progress from neutral to more sensitive topics

Ask permission to ask sensitive questions

Use the third person approach

Respect the young persons concerns and

point of view

HEADSS

H - Home
E - Education/Employment
A - Activities
D - Drugs
S - Sexuality
S - Suicide
Goldenring and Cohen, 1988

Developmental perspective

A developmental perspective

Exploratory sexual behaviour

Falling in love

Going all the way

Not everybodys heterosexual

Bennett, 1995

Sexually vulnerable
Young people:

Have more partners

Have sex more often

Are less likely to use condoms

Are more vulnerable to STDs

Sexual history: style

Permission and explanation

Gender-neutral, non-technical language

General to specific questions - 3rd person approach

Be explicit re behaviours, anatomy

Explore feelings, communication,

relationships, supports

Sexual history: content

Onset of sexual intercourse

Partners gender and number

Duration of relationships

Sexual behaviour/contraception

Safer sex messages for young

people

Abstinence works

Think ahead about your limits

Talk about your feelings

Keep a clear mind

Protect your self respect

Always use condoms during sex

A clinical perspective

Teenage pregnancy, parenthood and abortion

Gay and lesbian sexual health issues

Sexually transmitted diseases & HIV/AIDS

Impact of sexual abuse and exploitation

Implications of chronic illness/disability

IMPORTANT DETAILS
LMP-

regular/irregular cycles
Approximate time of ovulation
Penetration- vaginal/anal-penile/digital/sex
toys
Ejaculation
Barriers used

Intervention
Attend

to medical emergency
Emergency Contraception- option of
pregnancy
Discuss with family and the young person
Psychiatric Emergencies

EMERGENCY
CONTRACEPTION-the morning
after pill

Medically warranted
Efficacy reduced if taken >than 24 hrs of
intercoursesex between 11-16 days of a 28 day cycle
Ethinyl oestradiol 100ug+LNG 500ug-4tabs of
Microgynon 30/
Progestron only method-750ug 2 doses apart
Severe nausea and vomiting

Post Exposure Prophylaxis

Increased

risk in rape compared to

consensual sex
Rape- more genital trauma and bleeding
Multiple assailants
Vaginosis, Trichomonasis, gonorrhoea &
Chlamydia- increases risk of transmission

Probable of HIV +(High Risk)

IVDU
Bisexual/Homosexual
High

seroprevalence populationprison,rehab centres

Practises unsafe sex

HIV transmission with different

modes of exposure
Receptive

anal intercourse

10-30/ 10000 exp

Receptive

vaginal

8-20

Insertive
Insertive

anal sex

vaginal
Needle sharing
Needle prick injury

3
3-9
67
30

Effectiveness of treatment
Time

from exposure (max effectiveness

within 2 hrs, ineffective beyond 72 hrs)

Compliances

with treatment

PEP
Evidence of penetration
Unknown

Assailant HIV +

Assess probability

high
Zidovudine 250 mgs bd
Lamivudine 150mgs bd
Indinavir 800mgs tds

AZT 250mgs bd
Lamivudine 150 mgs bd

low
No pep

PEP advise
Window

period
Baseline antibody testing
Second test after 6 months
Follow up counselling
Side effects of medication
Safe sex with partner till 6 months

Legal Issues
Statutory

rape

Criminal

offence

Legislation relating to Children

Scattered

in various Acts with the principal Act on

protection being the Child Act 2001

The

concept of legal pluralism forms an important

element of the law i.e. there are different laws
applicable to different segments of society.
Public laws apply universally
Private laws uniformed laws for Non-Muslims &
state enactments to the Muslims

Kanak-kanak yang
memerlukan pemeliharaan
dan perlindungan

Yang didera atau diabai

Yang memerlukan rawatan perubatan
Yang kelakuannya boleh memudaratkan
dirinya sendiri
Keretakan dalam hubungan kekeluargaan
Yang mengemis atau menjaja

Kanak-kanak lain yang

dilindungi dibawah Akta 2001
Kanak-kanak

yang memerlukan perlindungan dan

pemulihan yang didorong melakukan perbuatan
seksual atau dalam persikitaran yang membawa
kepada perbuatan itu
Pemerdagangan dan pemelarian kanak-kanak
Kanak-kanak yang melakukan jenayah
Kanak kanak yang tidak dapat dikawal

Pemeriksaan dan rawatan

perubatan
Seksyen 21
Seseorang pegawai perubatan yang ke
hadapannya seseorang kanak-kanak dikemukanan
di bawah subseksyen 20(1) atau (4)

(a) Hendaklah menjalankan atau

menyebabkan dijalankan pemeriksaan ke
atas kanak-kanak itu

Pemeriksaan dan rawatan

perubatan
Seksyen 21
Seseorang pegawai perubatan yang ke
hadapannya seseorang kanak-kanak dikemukanan
di bawah subseksyen 20(1) atau (4)

(a) Hendaklah menjalankan atau

menyebabkan dijalankan pemeriksaan ke
atas kanak-kanak itu

Kebenaran untuk dimasukkan

ke hospital
Jika

pegawai perubatan yang memeriksa seseorang

kanak-kanak di bawah seksyen 21 berpendapat
bahawa kanak-kanak itu perlu dimasukkan ke
hospital bagi maksud pemeliharaan atau rawatan
perubatan, seseorang Pelindung atau

pegawai polis boleh membenarkan kanakkanak itu dimasukkan ke hospital

Public law
Private law
Child Act 2002
Adoption Act 1952
Child Care Centres
Registration of
Act 1984
Adoption Act 1952
Domestic Violence Act Guardianship of
1994
Infants Act 1961
Education Act 1974

Legally, the law works twofold:

PROTECTION

PREVENTION

of children in need by
way of affording
protection
(immediate/
temporary/ long-term)
& medical care where
necessary

(general & specific)

of future & repeat harm
by punishing those
responsible & by
preventing harm from
recurring

MANDATED INFORMERS

MEDICAL OFFICER &

PRACTITIONERS

CHILD CARE
PROVIDER

FAMILY
MEMBERS

MEDICAL OFFICERS &

PRACTITIONERS

27
Includes both doctors
at public & private
hospitals/clinics
Registered

Medical
Practitioners:
registered under
Medical Act 1971

Mandatory reporting
Failure

to inform the Protector can be subject,

upon conviction to a fine not exceeding RM5000
or to imprisonment for a term not exceeding 2
years or both

ADDED DUTIES OF THE

MEDICAL PRACTITIONERS
To conduct

the necessary examination for the

purposes of diagnosing the childs condition (s
21);
If treatment required is for a minor illness/injury
or treatment, a Protector or police officer can
authorise such treatment (s 24(1))
If child is suffering from serious illness/injury or
condition, Protector/police officer shall:

a)

b)

Notify parent/guardian to obtain consent &

accordingly authorise such
medical/surgical/psychiatric treatment necessary;
If medical officer certifies in writing that there is
immediate risk, Protector may authorise even
without obtaining prior consent in (a) for such
treatment to be performed but only in following
circumstances:

Offences & Penalties

Ill-treatment,

neglect, abandonment or
exposure of children s 31RM20000/imprisonment 10 years or both
Causing/procuring children for begging s
32 - RM5000/ 2 years/both
Leaving children without reasonable
supervision s 33 - RM5000/ 2 years/
both

CONCLUSION
Key challenges in Malaysia involved:
1. Ensuring existing laws are implemented &
enforced adequately
2. Ensuring that enforcement mechanisms
are in place to ensure compliance to the
law