The child rape epidemic.

To the Editor: We wish to comment on the clinical review of 294 cases of child sexual abuse. 1 A bias towards significant surgical injury may exist as the Department of Surgery at Red Cross Children's Hospital (RCH), which is a referral centre for managing child sexual abuse of all types, has the more severe cases referred. A case is made for examination under anaesthesia (EUA). Paediatric anaesthesia is highly specialised and best performed in centres of excellence; its unnecessary use should be avoided as it carries its own morbidity and mortality. Many clinicians, supported by protocols in other centres, hold that most children do not require EUA. Difficult cases or uncertainty and examiner inexperience are indications for referral and possible EUA. The use of EUA is perhaps contradictory to the authors' suggestion that it is '… perhaps time to encourage nursing staff to become qualified sexual assault nurse examiners to perform most of the examination'. Most sexually abused children presenting to health services have been chronically abused, therefore indications for EUA are less as they are often pathologically cooperative with clinical examination. It is traumatic for children to be taken from place to place, waiting for transport, etc. The provincial guidelines for management of child sexual abuse suggest that children should be seen and managed close to their communities, with support from the local police and social services. Primary and secondary level health care workers have provided positive feedback on this point, and it is supported by the Women and Children's Directorate of the Provincial Government. We acknowledge the services that social service agencies render within our communities. With inadequate resources, organisations such as Cape Town Child Welfare, the Department of Social Services and the Afrikaanse Christelike Vroue Vereniging use innovative methods with community involvement, and carry huge workloads. RCH is the only designated children's hospital in the country, and would be overwhelmed if all the approximately 18 000 raped children (the annual number of sexually abused children reported, according to the South African Police Service) were seen there. It would be greatly preferable to decentralise the management of sexually abused children and to equip all health centres to deal with them adequately and effectively. Problems with implementing the provincial guidelines require ongoing training and education of junior doctors, improved referral processes to avoid delay, better links with Police Family Services and the prosecution process, and improved community social …