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CMAJ - March 21, 2000JAMC - le 21 mars 2000

MD's gentle approach eases trauma of sexual abuse

Richard Cairney

CMAJ 2000;162:956

The street Dr. Marlene Lidkea lives on is kid territory. Youngsters were throwing a football around on the well-manicured keyhole crescent in St. Albert, an upscale suburb north of Edmonton. Others were riding their bikes, and Lidkea's yard was littered with the debris left in the wake of children hard at play. A set of goalie pads, a hockey net and sticks took up much of the driveway; nearby, a small mountain bike rested on its kickstand, with a cycling helmet hanging carefully from the handlebars. In other words, Lidkea is surrounded by children, and this probably helps explain the job she has taken on.

Dr. Marlene Lidkea: a willingness to investigate
(Photo courtesy of Darren Greenwood)

Twelve years have passed since she first treated a child victim of sexual assault, and she's seen many more horrifying cases since. However, she has made these cases easier to handle for both patients and doctors by developing an exhaustive set of diagnostic criteria, a protocol that has since been adopted by the Alberta Medical Association as a standard procedure for dealing with children who have been physically or sexually abused.

Lidkea says the first step is often the most difficult in treating these patients. One recent case she reviewed revealed that a preschool patient had been treated time and again for urinary tract infections. However, when Lidkea examined the child, she found evidence of sexual assault.

"She had scarring in her vagina from being abused. She was complaining, 'it hurts in my pee pee' and 'it hurts in my bum,' but no one examined her. There are lots of physicians who don't examine little girls' genitalia, partly because they don't want to be seen to be abusing the patient themselves."

Then there's the spectre of appearing in court to give evidence about a victim's physical condition. Doctors who are unfamiliar with the judicial system might prefer to avoid it altogether, she said. Others, particularly in remote rural centres, may want to avoid the issue because they know that the mere suggestion that a child is being abused can quickly turn into an accusation. "It can be handled in ways that are nonoffending," Lidkea explained. "The parent, usually the mother, doesn't have to feel threatened by the way questions are asked."

Lidkea said parents can be put at ease by being told that the questions are part of many examinations, and then by being asked if they've had any concerns that someone might be abusing their child. "I also take the opportunity to tell them it's not a bad idea to start talking to their kids about good touching and bad touching, even at 3 or 4 years old."

Lidkea began working on her protocol 3 years ago because she became frustrated that one didn't exist. Word of her gentle manner with young patients and her willingness to investigate such claims spread, and police from St. Albert and Edmonton began making appointments at her St. Albert family practice so that possible victims could be examined. She started delivering lectures on the subject to medical students at the University of Alberta and spoke to police, social workers and other doctors. Because she was already doing so much work in the field, Lidkea decided to create the province's treatment protocol. And now, thanks in no small part to those efforts, the health authority serving both cities has formed a Child and Adolescent Protection Unit.

Lidkea knows the work can be disturbing. "I've had cases where the physical damage has been horrendous: children covered in bruises and broken bones and with tears in their vaginas and bums, and yet they remain amazingly stoic and good spirited."

She's confident that most doctors can handle the work. The protocol she has created is in a 50-page book, with worksheets that doctors can photocopy and use to chart cases.

"What I'd like physicians to learn is that there are ways to approach the subject without alienating anybody and ways of handling children without traumatizing them.

"The other thing I'd like them to learn is not to be afraid to call child-welfare [authorities]. There are a lot of misconceptions that child welfare will swoop in and take children away from wonderful parents. [These child-welfare authorities] often have resources for people who aren't the best parents in the world — day care for 1 day of the week, or parenting courses. But they're not there to yank kids from good homes."

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