Good touch, bad touch

With the recent and highly publicized tragedy involving a Delaware pediatrician arrested and charged with 471 criminal counts of sexual abuse of patients over the course of 12 years, I believe we are all called on to examine our office practice of examination and anticipatory guidance. It has been suggested, by the media at least, that a factor in the abuse cases might be that our current "good touch, bad touch" teaching tells children that only parents and doctors may touch them in sensitive places.

As I listened to the news reports, I thought back on my own practices and realized that the following clinical pearl might be useful to others. Any time I examine a child more than about the age of 3 (and less than, say, 13) below their underpants, before I pull down their underpants, I point at them and say, "So, who is normally allowed to look down here?" The child will sometimes point at a parent, sometimes shrug, look blank, or even point at me.

I look to the caregiver for guidance here and say, "Is that right? Only mommy/daddy/grandma (etc), right?" Then I ask the child, "Can doctor look?" and mostly get yes as an answer. I then answer myself, "NO! Only if mommy or daddy is in the room, right? If mommy or daddy went outside, I couldn't look anymore, right?"

The caregivers look sometimes surprised, but mostly relieved.I think the relief might be that I have brought up a sensitive topic and have shown them how they can bring it up with their kids, too.

Most parents do say that they talk to their children about who can touch them but are surprised that when I ask, their children don't seem to know anymore. Therefore, more specifically, I have opened the door to talking about how power relations can convince children to do things, like letting someone else look at their genitals, that they have been specifically told by their caregivers not to do. I can then reinforce their caregivers' teaching and empower children to say "no."

Though this is something I developed in residency, every time I use this particular piece of anticipatory guidance now, it is with a heightened sense of its importance and possible preventive power.

CASEY ROSEN-CAROLE, MD, MPH, FAAP KINGSTON, NEW YORK