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Editor,—We were surprised to read of the letter from Hodes et al justifying a second examination of three girls suspected of being sexually abused.1 The triplets were presumably prepubertal? Were the photographs taken by the first paediatrician inadequate, and if so, why? A clinical diagram complemented by good quality photography usually provides adequate documentation, especially for prepubertal girls. Although the girls were compliant and the doctors no doubt sensitive, children do not like being examined and three paediatricians, the girls' mother, and a nurse (recommended by the General Medical Council), and in some areas, a policewoman, suggests an overcrowded examination room.
Colposcopy with integral photography has improved the quality of recording and the photographs are part of the casenotes. Discussion of individual cases by a peer group is well established, and slides or other recorded images are an essential part of this process. They may be used to detect subtle changes when a follow up examination is performed later. They have been shown to assist in differential diagnosis—for example, healing trauma versus evolution of a disease process. The doctor can never guarantee that the photograph will only be used for clinical purposes and teaching. The court has the power to direct that the slides are made available, hopefully to a named paediatrician.
We have used a colposcope mounted video camera with remote television monitor to allow trainees to observe the examination from an adjacent room with consent from parents and children as appropriate. The use of a one-way screen also enables the child's demeanour to be observed during the interview phase of the consultation.
Pretrial meetings clearly have a place in assessing medical evidence, but re-examination, even if the children are well prepared, always needs justification.
Dr Hodes and colleagues comment:
We agree that, as a general rule, re-examination should be avoided, but would argue that there are some circumstances in which it may be in a child's best interest. We accept that such circumstances will be controversial and require justification.
The triplets were prepubertal and although the still photographs were adequate there were different opinions at the peer review group as to their interpretation. As we stated, most differences could not be resolved by discussion alone. We did debate the ethical aspects of re-examination in detail because there may be harm to children in this process. However, had there been any evidence of discomfort or distress to the children we would not have proceeded with the examination. We did respect their wishes and a fair decision concerning their placement was possible. On balance, the overall benefits outweighed the harm.
It is well known that examination of the genitalia is a dynamic process and we accept that a videorecording is the gold standard that permits evaluation of changes in hymen configuration. However, not all units have access to video colposcopy facilities so disputes will occur over interpretation of still photography.
We offer review appointments to children and families after medical examinations to clarify understanding of the findings and their significance. In general the response to the experience of examination has been positive, as was indeed the ease with the three children we described.
We are sure that debate in this controversial area will continue.
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