Sexual Assault: The Medical Evaluation & Forensic Evidence Collection

Size: px

Start display at page:

Download "Sexual Assault: The Medical Evaluation & Forensic Evidence Collection"

Mary Gallagher
5 years ago
Views:

1 Sexual Assault: The Medical Evaluation & Forensic Evidence Collection North American Society of Pediatric and Adolescent Gynecology Annual Conference and Research Meeting April 7, 2016 Casey Weary, RN, BCN, SANE-P Marcella Donaruma, MD, FAAP Disclosure I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity I do not intend to discuss an unapproved/ investigative use of a commercial product/device in my presentation. Page 1 1

2 Objectives Discuss potential findings on physical exam and how to interpret them in the context of child history Understand when evidence collection is indicated Describe technique for evidence collection Page 2 What happens during a medical eval? HISTORY Physical symptoms Behavioral (emotional) symptoms Past medical history, social history, [sexual history], immunizations, medications, allergies History of present illness (DISCLOSURE) PHYSICAL EXAM SPECIMEN COLLECTION (labs, kit) Page 3 2

3 Medical provider takes medical history Page 4 History + Physical Impression + Plan Child s history is obtained in a non-judgmental, empathetic manner Discussion is consistent with the child s developmental level Non-leading, open ended questions are used History is documented accurately (preferably verbatim, at least with quotes around pertinent data) Page 5 3

4 History example #1 7 year old female reports that mother s boyfriend performed penile-vaginal contact, fondling and kissing repeatedly. Page 6 History example #2 HAS ANYONE EVER TOUCHED YOU ON YOUR PRIVATE PART? "It did not feel good." WHO WAS IT WHO DID THAT? "NAME." (name of mother s paramour) WHAT DID *NAME OF AP* TOUCH YOU WITH? "His hands, that's all. And his butt, his mouth. His breath smells like poop. How could my mom like someone with breath like that? He kissed my sister for a very long time. He puts his tongue all over my teeth. Isn't that gross?" I HAVE A QUESTION ABOUT SOMETHING YOU SAID. HOW DID HE TOUCH YOU WITH HIS BUTT? "It looks like a bat, but it's big and fat, then there's this round thing in the middle - it's like, like he has three legs. I imagine he's an alien. Probably." Page 7 4

5 When should a child be referred for medical evaluation? Anytime there is contact of the child s genital or anal area, skin to skin or with object. If there is oral sex performed on the child or perpetrator (genital or anal). The child does NOT have to describe penetration. Concern a limited disclosure has been provided, or even when recantation occurs. Page 8 Physical exam Page 9 5

6 The Hymen! Page 10 The Hymen the Mythology Page 11 6

7 The Hymen Mythology The opening to the vagina is covered at birth Page 12 The Hymen Mythology The doctor can tell by looking if patient has been assaulted Page 13 7

8 The stuff we do know Every normal baby girl is born with a hymen If the hymen has no opening, that is abnormal Configuration may change over time Page 14 How to find the anatomy Page 15 Lahoti, SL, McClain, N, Girardet, R. Evaluating the Child for Sexual Abuse. American Family Physician (2001); 63:

9 Knee-chest position Page 16 How to Find the Anatomy Labial Separation Labial Traction Childabusemd.com/physical-exam/genital-exam.shtml Page 17 9

10 Points of a good physical exam Was is documented in detail? A thorough examination should include documentation of the appearance of the labia majora, the labia minora, the hymen, the perihymenal tissue, the perineum, the anus, and the buttocks Were photographs taken? Ideally y with colposcope Does the examiner routinely participate in peer or expert review? Page 18 Anatomy-Quick Review Clitorisi Urethra Hymeneal rim Hymen Labia minora Posterior fourchette Anus Page 19 10

11 Main Hy-Points Tanner Staging I, II, III - shaved Estrogenized or Unestrogenized? Page 20 Unestrogenized or Estrogenized? Page 21 11

12 Main Hy-Points Tanner Staging I, II, III - shaved Hormone Effect Unestrogenized or Estrogenized? Configuration o Typically, crescentic or annular Page 22 Configuration Crescentic or Annular Page 23 12

Configuration Typically, crescentic or annular Injury

13 Main Hy-Points Tanner Staging I, II, III - shaved Hormone Effect Unestrogenized or Estrogenized? Configuration Typically, crescentic or annular Injury Inspect both the rim and the base of the hymen Page 24 Variations in the Hymen Page 25 13

14 Page 26 Page 27 14

15 Page 28 Page 29 15

16 The Anal Exam Page 30 What are we looking at? Page 31 16

17 What are we looking at? Page 32 What are we looking at? Page 33 17

18 What are we looking at? Page 34 What we know about anatomy It s normal to be normal Page 35 18

19 It s normal to be normal 5 year period, 2384 children were referred to a tertiary referral center for possible sexual abuse Referred e ed after disclosure of abuse, because of behavioral a change, exposure to an abusive environment, and because of possible medical conditions 68 % of the girls and 70% of the boys reported severe abuse, defined as penetration of the vagina or anus 96.3% of all children had a normal medical examination Heger A, Ticson L, Velasquez O, Bernier R. Children referred for possible sexual abuse: medical findings in 2384 children.child Abuse & Page Neglect ; 26: What we know about the anatomy It s normal to be normal Normal does not mean nothing happened Page 37 19

20 Normal does not mean nothing happened Review of the cases of 36 adolescents who were pregnant at the time of exam, or shortly before the exam Avg age 15 years 1 was pregnant with second child, 1 had a miscarriage, 1 had an abortion ONLY 2 patients had definitive findings of penetrating injury Kellogg, ND, Menard, SW, Santos, A. Genital anatomy Page 38in pregnant adolescents: Normal does not mean nothing happened ;113:e67-e69. Why is this so? Possible explanations Penetration does not always cause injury Acute injuries may occur, but then heal completely This type of tissue is made for this type of contact - once puberty hits Disclosure is often delayed Page 39 20

21 Mimics of Sexual Abuse Page 40 Mimics of Sexual Abuse Page 41 21

22 What was that? Lichen sclerosus et atrophicus Skin condition in which the vulvar skin becomes thin, itchy, easily damaged Results in raw appearance, bleeding, and blisters which may become blood-filled Not abuse! Page 42 Car accidents Boos SC, Rosas AJ, Boyle C, McCann J. Anogenital injuries in child pedestrians run over by low-speed motor vehicles: Four cases with findings that mimic child sexual abuse ;1112:77-84 Page 43 22

23 Boos SC, Rosas AJ, Boyle C, McCann J. Anogenital injuries in child pedestrians run over by low speed motor vehicles: Page 44 Four cases with findings that mimic child sexual abuse ;1112:77 84 Boos SC, Rosas AJ, Boyle C, McCann J. Anogenital injuries in child pedestrians run over by low speed motor vehicles: Page 45 Four cases with findings that mimic child sexual abuse ;1112:

24 How does this happen? Increase in pressure inside of the abdomen leads to rupture out of the anogenital area Traction from the tire rolling across the anogenital area causes tearing of external structures Page 46 Mimics of Sexual Abuse Page 47 24

25 Behcet s Disease Autoimmune condition that causes painful genital sores Page 48 Mimics of Sexual Abuse Page 49 25

26 Other mimics Various infections of the vaginal tissue can mimic trauma because they cause bleeding and swelling Page 50 Normal vs. Abnormal Why do an exam if it is highly likely to be normal? Is the victim a virgin? Page 51 26

27 FORENSIC EVIDENCE COLLECTION KIT Page 52 Page 53 27

28 What is the yield of a kit (FEK)? Review of 273 prepubertal children in Philadelphia with medical evaluation and FEK completion Christian CW, Lavelle J, DeJong AR, Loiselle J, Brenner L, Joffe M. Forensic evidence findings in prepubertal victims of sexual assault :106 Page 54 (1): Conclusions of this study: Swabbing the child's body for evidence may not be helpful after 24 hours. Clothing and linens yield the majority of evidence and should be pursued vigorously for analysis. Christian CW, Lavelle J, DeJong AR, Loiselle J, Brenner L, Joffe M. Forensic evidence findings in prepubertal victims of sexual assault :106 Page 55 (1):

Collection of evidence beyond 24 hours post assault: 277 evidence-collection kits were reviewed from the Houston Police Department Crime Laboratory. All kits were from children 13 years or younger.

Collection of forensic evidence from pediatric victims of sexual Page assault. 56. 2011 Aug; 128(2): 233 8.

29 Collection of evidence beyond 24 hours post assault: 277 evidence-collection kits were reviewed from the Houston Police Department Crime Laboratory. All kits were from children 13 years or younger. 222 kits (80%) had 1 or more positive laboratory screening test, of which 56 (20%) tested positive by DNA. Girardet R, Bolton K, Lahoti S, Mowbray H, Giardino A, Isaac R, Arnold W, Mead B, Paes N. Collection of forensic evidence from pediatric victims of sexual Page assault Aug; 128(2): The Time to evidence collection for kits testing positive for DNA: < 24 hrs for 30 (54%) hrs for 9 (16%) kits hrs for 3 (5%) kits hrs for 2 (4%) kits Girardet R, Bolton K, Lahoti S, Mowbray H, Giardino A, Isaac R, Arnold W, Mead B, Paes N. Collection of forensic evidence from pediatric victims of sexual Page assault Aug; 128(2):

30 Conclusions of this study: Body samples should be considered for children beyond 24 hours post assault Overall, children <10 with positive DNA evidence, the source was more likely to be from a non-body specimen This further supports the collection of clothing and linens Girardet R, Bolton K, Lahoti S, Mowbray H, Giardino A, Isaac R, Arnold W, Mead B, Paes N. Collection of forensic evidence from pediatric victims of sexual Page assault Aug; 128(2): What we can conclude from a kit: We do NOT know the appropriate maximum time interval for evidence collection in prepubertal children. The hope of collecting evidence must be weighed against the emotional needs of the child. A modern scientific study to evaluate rape kits in prepubertal children is needed. Page 59 30

31 When to request evidence collection <96 hrs Immediate forensic exam Non-acute cases Most cases present days to months to years after the event Decreased chance of finding evidence on exam Evidence collection is appropriate even when physical findings are normal or nonspecific Page 60 Evidence Collection Swabs Swabs will be included in the kit and should be used for oral, fingernails, genital and any areas that may contain DNA from the assailant. Always use a rolling technique to ensure entire swab is utilized 2-3 swabs should be used per area. To ensure an equal amount of DNA is on the swab you should swab simultaneously. Any skin findings such as a hickey, bite mark or dried secretions use the wet-to- to dry swab technique. If needing buccal swabs to identify the victim s DNA, make sure this is done after collecting the oral swabs for testing and the mouth is rinsed. Page 61 31

32 Nonbody Specimens The victim s narrative can provide additional information that can assist with evidence collection. If the assault was vaginal/penile/anal the underwear and pants are of GREAT importance Linens or clothing that may have DNA on them (i.e. dried semen on towel) All items should be dried and placed in paper or cardboard only, never plastic Page 62 Chain of Custody All swabs and evidence envelopes should be labeled and signed by examiner Tamper resistant tape Seals the kit Seal should be signed and dated by examiner No holes or openings should be present in the outermost packaging. The examiner should secure the kit in a locked area until it is released to law enforcement Page 63 32

33 THE MEDICAL IMPRESSION Page 64 Page 65 33

34 Page 66 Page 67 34

35 What we can conclude from exam and lab information Levels of certainty RE: sexual contact Normal Non-specific Indeterminate Supportive Indicative Diagnostic Page 68 What we can conclude from exam and lab information Diagnostic Laboratory evidence Pregnancy Sperm STD Normal Non-specific Indeterminate Supportive Indicative Diagnostic Page 69 35

36 What we can conclude from exam and lab information Diagnostic Laboratory evidence Pregnancy Sperm STD Gonorrhea Chlamydia Trichomonas HIV Syphilis Hepatitis C Normal Non-specific Indeterminate Supportive Indicative Diagnostic Page 70 Should you test for STIs after acute assault? Page 71 36

37 Implications of STIs in prepubertal children Chlamydia diagnostic of sexual contact in children >2 y.o. N. gonorrhea diagnostic of sexual contact Syphilis diagnostic of sexual contact HIV diagnostic of sexual contact t Page 72 AAP Red Book Implications of STIs in prepubertal children Trichomonas very suspicious for sexual contact Condyloma Genital herpes Bacterial vaginosis suspicious for sexual contact suspicious for sexual contact inconclusive Page 73 AAP RedBook 37

38 When to test? Disclosure of genital contact Signs or symptoms consistent with infection STI present in a family member/ap Patient has STI risk factors Significant concern of patient or parent Page 74 What we can conclude from exam and lab information Indicative Normal Non-specific Indeterminate Supportive Indicative Diagnostic Page 75 38

39 What we can conclude from exam and lab information Indicative of Blunt Force [Penetrating] Trauma Genital Injury Normal Non-specific Indeterminate Supportive Indicative Diagnostic Page 76 What we can conclude from exam and lab information Indeterminate This finding is seen in patients who are sexually abused but this finding also can have other explanations Normal Non-specific Indeterminate Supportive Indicative Diagnostic Page 77 39

40 What we can conclude from exam and lab information Indeterminate This finding may Support Aisha s history of penilegenital contact if a disclosure was made. Normal Non-specific Indeterminate Supportive Indicative Diagnostic Page 78 What we can conclude from exam and lab information Indeterminate A clear and consistent disclosure from the child is the most reliable indicator that abuse has occurred Normal Non-specific Indeterminate Supportive Indicative Diagnostic Page 79 40

41 What we can conclude from exam and lab information Non-specific Red down there This finding is not specific in the diagnosis of sexual abuse. Normal Non-specific Indeterminate Supportive Indicative Diagnostic Page 80 What we can conclude from exam and lab information Normal A normal exam neither rules out or confirms the occurrence of sexual abuse. Normal Non specific Indeterminate Supportive Indicative Diagnostic Page 81 41

42 What we can conclude from exam and lab information Normal A normal exam neither rules out or confirms the occurrence of sexual abuse as Kierra describes. Normal Non specific Indeterminate Supportive Indicative Diagnostic Page 82 Conclusions The most common finding in abused children and adolescents is a normal exam The statement no evidence of abuse does not reflect much understanding of the population of sexual abuse victims-try not to use it! Medical exams can (and do!) provide an assurance of normal to a child or adolescent victim Evidence collection recommended with ANY suspicion of skin-to-skin contact with GU area within ~ 96 hrs Page 83 42

43 Page 84 43

Sexual Abuse. Dr Burke Baird

Sexual Abuse. Dr Burke Baird Sexual Abuse Dr Burke Baird Unlike physical abuse, where you are typically faced with a suspicious injury and you go looking for an explanation, with sexual abuse, you usually start with a verbal disclosure