How to talk with children about sex

1. How to talk with children about sex Andrea Smith Paediatrician VFPMS Seminar 2017

2. Underpinning principles First do no harm (primum no nocere) Be open minded Seek the truth Be honest Be a team player

3. Primum no nocere Do respect child’s • developmental level, emotional state, willingness to talk • innocence and naivety • parents’ rights and feelings • family and cultural values

4. Primum no nocere Don’t • Introduce new words • Suggest scenarios, behaviours • Ask leading questions • Over-interpret words or behaviour

5. Be open minded Remind yourself that there is a range of possible outcomes Remain open to new, challenging and conflicting ideas and be prepared to change your mind Gather information THEN process it Avoid bias (learn about bias, minimise it)

6. Seek the truth A “disclosure” might not be the truth Ask yourself, “what if....?” • Misinterpreted by an adult (child’s comment, art, behaviour) • Misunderstood / misconstrued by child • Mistake • Mischief (ideas implanted by other) • Malice (fabricated by child)

7. Be honest Don’t overinflate expectations of outcome Don’t make promises you might not keep Fully inform, consent If in doubt, don’t (but consult) Own your errors Speak up if something is wrong Admit when you don’t know

8. Be a team player Understand the system Respect roles and responsibilities of police & child protection Police interview (VARE) before medical exam (whenever possible) Aim to minimise duplication & maximise efficiency Be reliable, dependable Act / Advocate for child & system

9. Before you talk with a child Understand child developmental pathways • Cognition, general behaviour • Sexualised behaviour Gather information from others • Carers • Police & child protection Plan approach to clinical evaluation of ?abuse Not one size fits all

10. Adapt approach to child Be flexible Child’s emotions, attitude and tiredness will affect the interaction Some children will promptly talk about the alleged abuse. Others will need prompts. Don’t interrogate. If child unwilling Adapt to developmental level: words/sentence = age(yrs) ?Separating child from parent (help or hinder) Child’s choice of support person (may change) Record children’s comments verbatim

11. Introduce yourself… Briefly explain role/experience “I have spoken to lots of children and families who have been in similar situations” Outline parts of assessment • Consent • History – general first • Examination, including “bottom” • Tell me, what name do you call the bits of your body normally covered by underwear or bathers? • What about (other gender), what are those bits called? • What words do your family use? • Investigations, what’s next

12. If allegation has been made – How do I start the conversation? Possible starters: • Why did you come here today? • Mum said that something happened on the weekend when you were with your cousins... • Dad said that you were worried about... • My job is to talk with you and have a look at you to try and understand what is going on

13. If no allegation – Good touches / Bad touches Not everyone uses this approach • I want to talk with you about the sorts of touches that people give and get from each other • Some touches feel really nice and we feel good about them… • Has anyone given you any “good touches”? • Some touches feel “not nice” and can make us feel hurt or sad or mixed up or they just don’t seem right somehow. • Has anyone given you any “not good” or “bad touches”?

14. Secrets: Good and Bad Not everyone uses this approach • Most children your age have secrets of some sort • Some secrets are good ones & we feel good about them, some secrets are not good ones, they feel “not nice” and can make us feel worried or sad or mixed up or they just don’t seem right somehow. • Do you have any good secrets? Who else knows? • How about the other sort? The “not good” or bad secrets. Do you have any secrets that make you feel bad? Who else knows?

15. Private parts You remember that we talked about the bits of your body under your bathers? Who is allowed to look at your ... and your ...? (And doctors, but only if it is OK with Mum & Dad and you) Has anyone who is not allowed to, looked at your ..? Who is allowed to touch your .... and your ....? Has anyone who is not allowed to, touched your ..? Finish with, e.g. “thank you for telling me this, I think that your body is yours and you decide if you want anyone to look at it or touch it”

16. Conversation enhancers Ah huh, (pause)... Mmmm, (pause)… Tell me more about that... What happened next? Can I check that I understood that correctly, did you say... (reflective listening) When you say “his thing” what do you mean? I think I know what you mean but I have to be sure

17. Don’t ask “Did it hurt?” • Most child sexual abuse doesn’t physically hurt children (Most abusers are known to the child and want to come back for more) • If it felt pleasurable then the psychological damage could be worse if idea created that it “should” have hurt. If child mentions pain, then can ask about it. “Did you bleed?” Avoid “did he /she... ” questions “Did he put his thing in your...” Never suggest a behaviour “Did anything come out of his...”

18. Do ask But only if relevant “What did that feel like?” “How did that make you feel?” “And when you did wee after that, how did that feel?” “Did he/she say anything else to you?” “Did he/she say anything about you telling anyone else about what happened?”

19. Keep your emotions in check Professionalism at all times No over-interested questions or harping on about something when child is uncomfortable No gasps of horror / shock / squirmimg No tears and sobs (from you) No visible signs of disbelief No impatience

20. Offer to answer child’s questions Always answer any questions the child/adolescent may have, honestly If perpetrator’s behaviour discussed – preferably don’t comment, label as “wrong”, not “bad / naughty” Clarify what will happen next in relation to your role & the investigation more broadly Offer again “is there anything else that I can do for you today?”

21. Positive comments “Your body is really healthy and strong. Your bottom (+ child’s word for genitals) look exactly right for a girl/boy your age” “No-one will ever know what happened to your bottom (+ word for genitals). The only way anyone will ever know is if you tell them”

22. Quit the patronising Respectful courtesy is best “I could see that you found it really hard to talk about some of the things that happened”. “Thankyou for telling me about ... even when it made you feel really upset to talk about it.” “I didn’t want to upset you but I did want to understand what happened so I could work out how best to help you.” “You were so brave” statements can seem hollow and fake so try to avoid unless true.

23. Finish with optimism “Thankyou for all your help today.” “Now that we know what happened ... Mum and Dad and all the people you have met this week will do everything we can to make things better for you”. “We want things like (what we talked about) to stop so you can enjoy being a happy girl/boy”. “I am very happy to see you again if you want to”.