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Protecting children from sexual abuse

Key learning points:

- Undertaking an elevated role within the multiagency arrangements that manage cases of child sexual abuse

- Nurses should have access to relevant learning opportunities and expertise to enable competency development in the recognition and response to child sexual abuse

- The primary care nurse is in a unique position to be able to offer or refer families for long term support if required

More than 2,800 children in the UK were identified as needing protection from sexual abuse last year, and with the physical signs sometimes hard to distinguish, child protection experts have launched updated guidance for all healthcare professionals to support examinations for child sexual abuse (CSA) - The Physical Signs of Child Sexual Abuse.

The guidance, also known as The Purple Book, brings together the latest knowledge and evidence to aid clinical decision making. This second edition includes three new chapters; anogenital signs of accidental injuries in girls and boys, genital bleeding in prepubertal girls and healing in anogenital injuries.

As some physical signs of child abuse can be difficult to interpret, this resource ensures that decision making is underpinned by scientific evidence. It also provides good practice guidance for health professionals to piece together additional information in order to inform the assessment such as: the history and context, the child or young person's behaviour and demeanour, and statements made by the child to professionals.

The Purple Book is predominantly aimed at clinicians who undertake forensic sexual abuse examinations, however, all healthcare professionals have a responsibility to protect children. Therefore it is a useful point of reference for any clinician who comes into contact with children, including primary care nurses.

Child protection - it's everyone's responsibility

A number of job roles fall under the umbrella term relating to the function of a primary care nurse. For example, a practice nurse, an advanced nurse practitioner or a nurse partner, however, irrespective of the job role, each nurse has the same professional standards to adhere to in the awareness and recognition of CSA and its forms.1,2

Child sexual abuse, whether recent or historic, is currently of elevated national importance, due to further high-profile historical CSA cases being reported to the lead authorities, the ongoing independent inquiry into child sexual abuse,3 and continuing reports that highlight systematic failures in protecting children and young people from child sexual exploitation (CSE), a form of CSA.4,5 This increased and continuing focus is likely to result in key changes to the child protection landscape, including consideration by governments for the introduction of legislation such as mandatory reporting of child protection concerns. Any potential change in both legal and professional duties for the reporting of child abuse will have implications for nurses in primary care settings along with other healthcare professionals and multiagency professionals.

Compared with some other nursing professions and multiagency professionals, primary care nurses have traditionally been very much on the sidelines of partnership working and have not been notably involved in multiagency CSA safeguarding interventions. However, with the emergence of clinical commissioning groups (CCGs) there is increasing recognition and expectation of these professionals' role in the management of CSA.

Despite this increasing role, learning opportunities may at times be limited. A recent report highlighted that CSE did not routinely appear in mandatory child protection training courses, and current knowledge was worryingly based on what participants heard or read in the media.6 The development of competencies through a variety of high-quality multiagency learning opportunities is therefore essential for enabling this professional group to reach the expected practice standards in respect of CSA.

Primary care nurses in a unique position

Primary care nurses with responsibility for their general practice population are in a unique professional position to support the identification of CSA,7 and are well placed to work with the short and long-term health consequences for victims of child sexual abuse.

In community based healthcare premises, practice nurses consult and deliver clinical interventions with children, young people and their families on a daily basis. The intelligence they gather during consultations and communications with children and young people could support the detection of CSA at both an individual and community level.

Detecting CSA

Effective professional communication helps establish a trusting and nurturing environment for a child or young person to disclose CSA, and can provide opportunities for nurses to assess for some of the less obvious signs that a child may have been or is at risk. The primary care nurse needs to understand the principles of this communication to support effective disclosure, while not compromising a criminal investigation. Although some children and young people seek an opportunity to disclose around the time the sexual abuse occurs, others may not present for several months or years after the abuse has taken place, with many waiting until adulthood to disclose. It's clear that disclosure has no fixed pattern so the primary care nurse must be able to develop his or her skills and competencies sufficiently to be able to recognise and respond sensitively yet professionally to any indicator or disclosure.

Children and young people who are victims of CSA may present alone or with others in primary care settings for services relating to the aftermath of CSA such as injuries, pregnancy, termination services, contraception advice, sexual health services, depression, self-harm, suicide attempts e.t.c. Therefore, it is vital that the nurse is able to assess and manage the clinical situation while being alert to the possibility of CSA. The aftermath of CSA is evidenced globally to have significant short and long-term physical and psychological health consequences on child victims and adult survivors. Evidence suggests that these victims will use primary care services more often than the non-abused general practice population.

Ensuring appropriate support

Nurses should have a clear understanding of the local procedures and protocols to follow for referring cases of CSA and know how to manage professional disagreement in respect of the management of these cases.

Speaking out about abuse requires a huge level of courage by the victim, so it is vital that the nurse believes a child who discloses CSA, supports other appropriate adults to respond sensitively to the child or young person, and avoids making false promises, clearly communicating to child, young person and/or family their duty as a health professional to proceed in the best interest of the child, remaining professional and sensitive at all times.

If sexual abuse is identified, it is crucial that the child or young person and their family are appropriately supported. Primary care nurses cannot provide interventions for all the health consequences that may arise following abuse, however they should know how to access local specialist and other support services such as sexual assault and referral services. In all cases consideration should be given as to the need for specialist therapeutic support, given the numerous emotional, behavioural and psychological consequences of CSA. To support practice nurses to refer appropriately, a toolkit or local directory of reputable and accessible services, developed in partnership with named and designated professionals, may be useful.

It is helpful for nurses to have an understanding of the emotional response families may have to a disclosure of CSA, particularly when the alleged abuser is a family member. It is also helpful for nurses to be prepared for situations where an allegation is retracted, and why some criminal investigations may not be successful.

While other professional groups involved in the assessment and management of an allegation of CSA may only have limited involvement with a child, young person or their family, practice nurses have the privileged position of being able to develop long-term, positive relationships, potentially maintaining the relationship when all other services have left and the investigation is completed.

The Purple Book can help

We are turning a corner in the way CSA is reported. And at a time where all professionals will be held accountable for not reporting suspected cases, it is vitally important that primary care nurses as well as other professionals that work with children understand the law and the requirements placed upon them.

The Purple Book is a useful resource for ensuring that all health professionals, including primary care nurses can access the knowledge, skills and evidence for identifying CSA.


To find out more about The Physical Signs of Child Sexual Abuse please visit the Royal College of Paediatrics and Child Health's website:


1. Nursing and Midwifery Council. The code for nurses and midwives. (accessed 24 August 2015).

2. Department for Education. Working Together to Safeguard Children, 2015. (accessed 24 August 2015).

3. Independent inquiry into sexual abuse. Investigating the extent to which institutions have failed to protect children from sexual abuse (accessed 24 August 2015).

4. Rotherham Metropolitan Borough Council. Independent Inquiry into Child Sexual Exploitation in Rotherham (1997-2013). (accessed 24 August 2015).

5. Oxfordshire Safeguarding Children Board. Serious Case Review into Child Sexual Exploitation in Oxfordshire: from the experiences of Children A, B, C, D, E, and F. (accessed 24 August 2015).

6. Kirtley P. If you shine a light you will probably find it. Report of a Grass Roots Survey of Health Professionals with Regard to their Experiences in Dealing with Child Sexual Exploitation, 2013. (accessed 24 August 2015).

7. Nursing Times. Keir Starmer: 'Nurses play a crucial role in helping to detect cases of child sexual abuse,' 2013. (accessed 24 August 2015).