Child Sexual Abuse: Overcoming Society’s Perceptions 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. If we accuse too early and then find it is not what happened what have we done to that innocent person and their future.

Goals The truth: Being able to establish through a good thorough investigation whether the injuries were inflicted or caused by an accidental occurrence.

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 friends

Your Victims?

Your Suspect?

What do YOU see……

What is NORMAL…..

Reasons Sexually Abused children Present to medical care Disclosure of sexual contact Behavior changes Medical complaint

Who would think this….. Survey of Pediatric residency training programs in US 142/195 programs responded Chief residents answered questions and reviewed anatomy diagrams

Dubow, et al. CAN 2005: Physician Knowledge of Genital Anatomy Take Home Points: Increased education, need for experienced/trained specialists doing examinations

Sexual Exposure

Purpose of the Medical Exam in suspected SA cases Injury identification Collect evidence STD screening/treatment Reassurance to child and parents

Adams. Pediatrics 1994: “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

Heger, CAN children; 5-year prospective study ( ); tertiary CA referral center. Children 3mo-14yo Mean age 6.9 yrs girls; 5.5 yrs boys ◦ Disclosing: 7.8yrs ◦ Non disclosing: 4.5 yrs

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.

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 ( ) Normal/nonspecific exam64% (n=22) Inconclusive finding22% (n=8) Suggestive8%(n=4) Definite penetration6% (n=2)

How do WE overcome the perception

The 72 Hour Rule: Based on Adults SPERM COUNT Sample Few Internal vaginal External vaginal Internal anal External anal33221 Oral/saliva2222N/A Estimated number of days from intercourse by sperm amount. (adapted from Allard JE, Science & Justice 1997;37: )

Christian, et al. Pediatrics 2000;106: 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 years

Christian, et al. Pediatrics 2000;106: 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.

Christian, et al. Pediatrics 2000;106: 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 mouth

Christian, et al. Pediatrics 2000;106: 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 found

Christian, et al. Pediatrics 2000;106: 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.

Christian, et al. Pediatrics 2000;106: Hours since sexual assault Any forensic evidence vs. time # of children

Christian, et al. Pediatrics 2000;106: Forensic evidence from child’s body vs. time. Hours since sexual assault # of children

Christian, et al. Pediatrics 2000;106: 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!

IT IS A PROCESS…..

Late outcries Why didn’t they tell Why did they tell Who did they tell

Other obstacles….. really

Children rarely tell right away.

There is rarely scientific evidence.

Perpetrators rarely dress in trench coats and hide in dark alleys.

Children often like or even love their perpetrator.

Moms will choose their boyfriends over their children.

There is no way to predict how a child will respond to sexual abuse.

Justice is rarely swift.

The words of the child are the “evidence” we rely on to prove a case.

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