Child's needs should be central

EDITOR,—I am concerned about some of the issues raised in the case discussed in the ethical debate about child protection.1 Given the nature of the case, it is entirely appropriate that social workers should have investigated it, as it was indeed an abuse of parental responsibility towards a child. I am not surprised at the child claiming that she must have slept through anything that happened. I have seen a teenage girl who denied the possibility of being pregnant despite having had no period for three months and having recurrent bouts of morning sickness, a positive result on pregnancy testing, and a viable first trimester fetus visible on ultrasonography. I suspect that the response of the child in the case debated reflects the human psyche's ability to deny unpleasant facts and should not be taken at face value.

The author tries to take an overview of his or her relationship with the entire family, with the result that the child's needs have become more peripheral than they should be. As medical professionals, we can manage only certain aspects of such complicated cases, and I believe that we are doing a disservice to the child if we do not involve other professionals more capable of continuing the investigations. It is by no means always the case that incest is disclosed at the time of a teenage girl's pregnancy being discovered. I would caution against the belief that “careful advice coming from a trusted doctor” is the input that a sex abuser needs.

Iona Heath's remark in her commentary on the case—that the outcome of these interventions rarely seems adequate—reflects a natural desire for a solution to what is an almost irreconcilable situation. My experience in paediatrics suggests that it is important not to ignore evidence that contradicts an apparently plausible explanation of such situations. I think that we do a disservice to young people, who need a voice and an advocate on their behalf. All too many victims of familial sexual abuse suffer in the long term; they are likely to leave home, which puts them at risk from other dangers, such as prostitution, drugs, and violence. We want to prevent the abused person from becoming a potential abuser. We protect the perpetrator at great risk to the victim.