Texas Association Against Sexual Assault Conference 2014 Reality Understanding society and what they think of these offenses Most do not believe or want to believe this is going on in their communities That those people they see on a daily basis could be abusing their kids ID: 551907
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Slide1
Child Sexual Abuse: Overcoming Society’s Perceptions
Texas Association Against Sexual Assault
Conference 2014Slide2
Reality
Understanding society and what they think of these offenses.
Most do not believe or want to believe this is going on in their communities. That those people they see on a daily basis could be abusing their kids.
If we accuse too early and then find it is not what happened what have we done to that innocent person and their future. Slide3
Goals
The truth: Being able to establish through a good thorough investigation whether the injuries were inflicted or caused by an accidental occurrence. Slide4
Welcome to Child Abuse
The victim waits to tell
There is rarely any scientific evidence
Often no one believes the victim
The victim loves the defendant
The victim has recanted
The victim is barely verbal
CPS and therapists are your new best friendsSlide5
Your Victims?Slide6
Your Victims?Slide7
Your Suspect?Slide8
Your Suspect?Slide9
What do YOU see…… Slide10
What is NORMAL….. Slide11
Reasons Sexually Abused children Present to medical care
Disclosure of sexual contact
Behavior changes
Medical complaintSlide12
Who would think this…..
Survey of Pediatric residency training programs in US
142/195 programs responded
Chief residents answered questions and reviewed anatomy diagramsSlide13
Dubow, et al. CAN 2005:195-205.
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7
4
1
2
5
3
Physician Knowledge of Genital Anatomy
Take Home Points: Increased education, need for
experienced/trained specialists doing examinationsSlide14
Sexual ExposureSlide15
Purpose of the Medical Exam in suspected SA cases
Injury identification
Collect evidence
STD screening/treatment
Reassurance to child and parentsSlide16
Adams. Pediatrics 1994: 310-317
“Examination Findings in Legally Confirmed Child Sexual Abuse: It’s Normal to be Normal”
Study looked at 236 children (<17
yrs
)
All cases the perpetrator was convicted or pled guilty
Examination findings:
Normal 28%
Non-specific 49%
Suspicious 9%
Abusive 14%
Best predictor of abnormal findings :
Time since assault
History of bleeding
Slide17
Heger
, CAN 2002
2384 children; 5-year prospective study (1985-1990); tertiary CA referral center.
Children 3mo-14yo
Mean age 6.9
yrs
girls; 5.5
yrs boysDisclosing: 7.8yrsNon disclosing: 4.5 yrsSlide18
Conclusions
Heger CAN 2002
Only 4% of all children referred for medical evaluation of sexual abuse have abnormal examinations at the time of evaluation.
Even with a history of severe abuse such as vaginal or anal penetration, the rate of abnormal medical findings is only 5.5%.
History from the child remains the single most important diagnostic feature in coming to the conclusion that a child has been sexually abused.Slide19
Kellogg, et al. Pediatrics 2004;113:e67-e69.
Genital Anatomy in Pregnant Adolescents:
“Normal” Does Not Mean “Nothing Happened”
Genital examination on 36 pregnant girls
Average age 15.1 years (12.3-17.8)
Normal/nonspecific exam 64% (n=22)
Inconclusive finding 22% (n=8)
Suggestive 8% (n=4)
Definite penetration 6% (n=2)Slide20
How do WE overcome the perceptionSlide21
The 72 Hour Rule: Based on
Adults
SPERM COUNT
Sample Few + ++ +++ ++++
Internal vaginal 7 7 3 1.5 1.5
External vaginal 7 3 2-3 2 1
Internal anal 2-3 2-3 2 1 1
External anal 3 3 2 2 1
Oral/saliva 2 2 2 2 N/A
Estimated number of days from intercourse by sperm amount.
(adapted from Allard JE, Science & Justice 1997;37:99-108.)Slide22
Christian, et al. Pediatrics 2000;106:100-4.
Forensic Data in
Prepubertal
Children
Retrospective Study (5 years)
Children < 10 years old
“Rape Kits” collected and processed
273 patients
78% girls
79% African American
Average Age: 5.3 yearsSlide23
Christian, et al. Pediatrics 2000;106:100-4.
Forensics:
Prepubertal
Children
PHYSICAL EXAM FINDINGS:
23% had acute
anogenital
injury
88% with injury seen within 24 hrs.
Injury associated with forensic findings (p < 0.001)
5 children with injury after 24 hrs, none with forensic evidence.Slide24
Christian, et al. Pediatrics 2000;106:100-4.
Forensics: Prepubertal Children
FORENSIC EVIDENCE found in 24.5%
64% found on clothing
11% from vagina
8% from anus / rectum
5% from secretions on body
2% from mouthSlide25
Christian, et al. Pediatrics 2000;106:100-4.
Forensics: Prepubertal Children
FORENSIC EVIDENCE FOUND:
14% of children had sperm found
11% had semen found
14% had blood found
3% had pubic hair found
< 1% had foreign debris foundSlide26
Christian, et al. Pediatrics 2000;106:100-4.
CHILDREN WITH FORENSIC
EVIDENCE:
All were seen within 44 hrs. of the assault
90% were seen within 24 hrs.
No sperm / semen from body found > 9 hrs.
No blood from body found > 13 hrs.Slide27
Christian, et al. Pediatrics 2000;106:100-4.
Hours since sexual assault
Any forensic evidence vs. time
# of
childrenSlide28
Christian, et al. Pediatrics 2000;106:100-4.
Forensic evidence from child’s body vs. time.
Hours since sexual assault
# of childrenSlide29
Christian, et al. Pediatrics 2000;106:100-4.
CONCLUSIONS
Time since assault is a useful clinical indicator for collecting forensic evidence.
Swabbing genitals futile after 24 hrs.
Collection from body unhelpful after 48 hrs.
Practices vary among institutions.
Don’t rely on child’s history of assault.
Don’t forget to collect the clothes!Slide30
IT IS A PROCESS…..Slide31
Late outcriesWhy didn’t they
tell
Why did they
tell
Who did they tellSlide32
Other obstacles….. reallySlide33
Children rarely tell right away.Slide34
There is rarely scientific evidence.Slide35
Perpetrators rarely dress in trench coats and hide in dark alleys.Slide36
Children often like or even love their perpetrator.Slide37
Moms will choose their boyfriends over their children.Slide38
There is no way to predict how a child will respond to sexual abuse.Slide39
Justice is rarely swift.Slide40
The words of the child are the “evidence” we rely on to prove a case.Slide41
Advantages of Teamed Investigation
Each agency contributes unique strengths to the investigation
Shared information & expertise
Reduces redundancy
Eliminates confusion
Reduces amount of trauma to survivors and non-offending caregivers
Higher level of success for criminal prosecution and civil court actions
Prevention of future abuse of children