Recently I saw a 13-year-old girl in surgery, let's call her Kelly, with her mum. Kelly's teacher at school had suggested she see her GP as her mood seemed to be low and they had seen evidence of wrist cutting. Earlier this year Kelly had disclosed to a teacher that she had been repeatedly sexually abused by her uncle and a court case was pending. The police inquiries had been ‘endless’, according to her mum and had resulted in her missing almost 2 weeks of school, which made her reintegration all the more difficult. She was referred to an inclusion centre within the school which offers smaller classes as she was unable to cope with the mainstream programme. Both Kelly and her mum were told by the police that she would not be able to have any counselling until the court case was concluded. She was referred to a ‘child protection’ social worker who repeated this message and informed the school that Kelly was not to have any form of counselling since it may compromise her testimony.
By the time Kelly turned up in surgery it was 4 months later and she was self-harming, not sleeping, and constantly arguing with her mum. They both attested to fully expecting their GP to also say they would not be able to talk to Kelly about her emotional wellbeing until the court case was over. They had effectively been silenced. No doubt the perpetrator of the abuse, carried out over a number of years, had also told Kelly she had no right to speak.
As a GP offering extended appointments for young people experiencing emotional distress associated with psychological problems, I have access to clinical supervision. When I explained the situation to the child psychiatrist offering supervision he directed me to Home Office guidelines1 which address in detail the tension between the potential contamination of evidence which may compromise a successful prosecution and the best interests of the child. They begin with the UN Convention on the rights of the child:
‘When adults or organizations make decisions which affect children they must also think about what would be best for the child’ (Article 3).2
Unfortunately the social worker was unaware of the guidelines. In addition she told me that both she and her manager were employed by an agency and lacked experience in this area and that furthermore she had found it ‘impossible’ to identify locally-based counsellors who were prepared to work with children who had disclosed sexual abuse where there was a pending court case. They were fearful of being called as witnesses and were unwilling to accept new referrals.
From the maxim ‘of every door an open door’ that has oft been aspired to regarding increasing access to health care for young people, we have a situation presented here where those most in need find every door closed. How can this be morally and clinically defensible? Can our legal, health, and social care systems be so impenetrable to compassion?
This situation resonates with the recent attention to the plight of victims of crime, brought to the fore by the Dowler family regarding their cross-examination in the recent trial of their daughter's convicted murderer.3 They argue that the right to a just trial protects the rights of the defendants above and beyond those who are its victims. It seems that in the case of children who have endured sexual abuse, often at the hands of known family members thus representing the grossest travesty of trust, the system continues to operate an inverse care law of compassion.
This surely needs addressing if we are to tackle the known and predictable human consequences of abuse of children and young people.
- © British Journal of General Practice 2011