Limits of the Medical Examination in Assessing Child Sexual Abuse BERNADETTE J. MADRID, MD DIRECTOR CHILD PROTECTION UNIT UP MANILA- PGH

MODULE : THE MEDICO-LEGAL EXAMINATION OBJECTIVES: To understand the purpose of the medico-legal examination To understand the meaning of the medical findings To be aware that there are many ways of abusing children without resulting in medical findings. METHODOLOGY: lecture, visual aids, open forum

Purpose of Medical Evaluation for Sexual Abuse 1. Evaluate Medical Problems 2. Gather Evidence 3. Aid Transition Into Therapy by providing a supportive and protective environment by giving feedback to the patient that her body is OK, despite the abuse

TYPES OF EXAMINATION: 1. Acute Evidentiary Exam (less than 72 hours) 2. Non-acute Exam (more than 72 hours)

TIMING OF MEDICAL EXAMINATION Immediate Examinations are required for: 1. History of sexual assault within preceding 72 hours. 2. History of genital or anal bleeding 3. Symptomatic Sexually Transmitted Infections (STIs)

EVIDENCE OF SEXUAL ABUSE 1. MEDICAL EVIDENCE Physical findings Forensics 2. CONVINCING DISCLOSURE BY CHILD 3. BEHAVIOR developmentally unusual sexual behavior knowledge or symptoms Depression, post-traumatic stress disorder 4. EVIDENCE THAT CORROBORATES THE ABUSE

MEDICAL EVIDENCE IN CSA ANO-GENITAL FINDINGS Laceration of the hymen Bruising of the hymen Perianal lacerations deep to the external anal sphincter Healed hymenal transection Absence of hymenal tissue

MEDICAL EVIDENCE Finding of sperm or seminal fluid on the child’s body Pregnancy Confirmed cultures of N. gonorrhea Evidence of syphilis acquired after delivery Cases where photographs or videotape show a child being abused HIV infection (not due to other causes like blood transfusion, etc.)

DISTRIBUTION OF PHYSICAL FINDINGS IN SEXUALLY ABUSED CHILDREN:

REASONS FOR ABSENCE OF PHYSICAL FINDINGS 1. Type of abuse 2. Deliberate avoidance to hurt child 3. Difference in child and adult view of “penetration” 4. Elasticity of hymen and anal sphincter

REASONS FOR ABSENCE OF PHYSICAL FINDINGS 5. Post-assault activities 6. Delay in disclosure / examination 7. Limitation of equipment / technique 8. Limitation of examiner

TYPE OF ABUSE CONTACT: Touching, fondling or oral contact Insertion of fingers or objects into vulva or anus Masturbation Intercourse Other genital contact ; intercrural Prostitution

TYPE OF ABUSE NON- CONTACT: Exhibitionism (flashing) Pornography of many kinds; photographing sexual acts or anatomy Showing pornographic photographs, films,video.

DELIBERATE AVOIDANCE TO HURT CHILD Skillful Perpetrator avoid hurting child Genital Trauma when assaulted by stranger (25%) vs. known assailant (12%)

DIFFERENCE IN CHILD AND ADULT VIEW OF “PENETRATION” Young children naïve about sexual practices, will usually not know that something can penetrate deep into the vagina. Their definition of “inside” may not turn out to actually mean deep or even any penetration

ELASTICITY OF HYMEN AND ANAL SPHINCTER Normal Genital Anatomy “Hymen Tissue is “ELASTIC” It can stretch to allow penetration, even in the pre-pubertal child. “full penetration…particularly in an older child, may cause no visible trauma…” (Bays & Chadwick, 1993; Huffman, Dewhurst & Capraro, 1981; Mahran & Saleh, 1964; Pokorny, 1987; Teixeira, 1981)

DAMAGE TO HYMEN MAY OR MAY NOT OCCUR DEPENDING ON: Size of child Size of penetrating object Amount of hymen tissue Amount of force

POST-ASSAULT ACTIVITIES Urination Defecation Genital wipe /wash Bath / shower Brushing of teeth Oral gargle / swish Change of clothing

DELAY IN DISCLOSURE / EXAMINATION History of Penetration  36% had genital trauma when examined within 24 hours  to 13% after 24 hours

LIMITATION OF EQUIPMENT / TECHNIQUE Colposcope Examining methods/positions Examining technique

Colposcopy

LIMITATION OF EXAMINER Lack of Special Training Personal biases

A CONSENSUS OF MEDICAL AND LEGAL PRACTITIONERS IN THE PHILIPPINES Child Maltreatment Medico-Legal Terminology and Interpretation of Medical Findings Good afternoon. I am pleased to present to you the Child Maltreatment Medico-Legal Terminology and Interpretation of Medical Findings, A Consensus of Medical and Legal Child Abuse Practitioners in the Philippines. A CONSENSUS OF MEDICAL AND LEGAL PRACTITIONERS IN THE PHILIPPINES

Technical Working Group Members CPU-PGH PNP NBI DOH Legal Luminaries This consensus is a product of representatives of these different agencies who conduct medical evaluations on children for possible sexual abuse and issue medico-legal certificates for this purpose. Since the end-users of these certificates are the lawyers and judges, we included legal luminaries to get their input on this most important document.

The Process Review of vocabulary used internationally Agree upon a lexicon Agree on definition of ambiguous terms Devise a common medical certificate It took us two years of meetings, consultations, deliberations, and more argumentations to “deliver this baby.” The steps included: (READ THE SLIDE).

Our Goals Improved technical understanding Ability to “speak the same language” Standardized procedures It is the genuine hope of the authors that, after reading this publication, users will have reaped the following benefits:   v     Improved technical understanding: By becoming more familiar with the child protection medical terminology and examination, members of the medical and legal community will have a stronger grasp of the information contained within the medico-legal certificate, reducing the possibility of misinterpretation. v     Ability to “speak the same language”: Child abuse occurs globally; hence, physicians must share a single vocabulary so as to better communicate ideas and best practices worldwide. v     Standardized procedures: The standardization of terminology and the certificate itself may lead to standardized procedures. If one comprehensive examination can be created and agreed upon by all members of the medico-legal community, there will be less cause for multiple exams and, thus, less possibility of re-traumatizing patients. Ultimately, it is our intention that this publication will serve as both an educational tool for child protection professionals unfamiliar with the medico-legal examination, and as a guideline for those in the medical community actually performing the examination.

HYMEN The most insignificant structure of the female with neutral value to health….

HYMEN “To say that this delicate piece of membrane is a far, from the nonphysical point of view, more important structure than any other part of the body is to convey but a feeble idea of the importance of the hymen in the eyes of the men…” (Wile, J Nerv Ment Dis, 1937)

Did you know that… the Philippines is the first country in the world to incorporate a uniform medico-legal terminology and certificate into its national child protection system! Did you know that… (READ THE SLIDE) This is something we can all be truly proud of.

GENERAL PHYSICAL FINDINGS ANO-GENITAL EXAMINATION MEDICO-LEGAL CERTIFICATE DEMOGRAPHIC DATA Patient’s Name   Age DOB Sex Patient’s Address Civil Status Occupation Nationality Requesting Party Place, Time and Date of Examination qNon-Acute Examination FINDINGS GENERAL PHYSICAL FINDINGS Height Weight General Survey Mental Status Pertinent Physical Findings/ Physical Injuries ANO-GENITAL EXAMINATION External Genitalia Urethra and Periurethral Area Perihymenal Area & Fossa Navicularis Hymen Perineum Discharge IE and Speculum Examination Anal Examination REMARKS Forensic Evidence and Laboratory Results IMPRESSIONS qAcute Evidentiary Examination (within 72 hrs of incident) Ladies and Gentlemen, I am proud to present the Standardized Medico-legal certificate agreed upon by our Technical Working Group.

Highlights: Latest findings Color NOT reliable in aging bruises Based on a recent systematic review of studies on aging of bruises in children by Maguire et al. in Archives of Disease in Childhood 2005 Recommended that more scientific research be done at this time that could give sound scientific conclusions on aging of bruises in children. I shall now present the highlights of the Consensus. Please walk through this Document with me. Firstly, this Consensus incorporates the latest in the medical field about the dating or aging of skin injuries. For contusions, latest research has shown that (READ THE SLIDE).

MULTIPLE BRUISES

Highlights: Latest findings Aging of Skin Lacerations Fresh (presence of fresh blood, edema): injury occurred within past 24 hours Healing (presence of granulation, no blood): injury occurred between 48 hours and 21 days Healed (with scar): injury cannot be dated accurately The latest research findings on the healing of skin lacerations are also incorporated, as shown.

Highlights: Gives a review of basic anatomy Hymenal orifice (vaginal opening) Labia majora Shaft     Hymenal membrane Urethral opening Dorsal vein Scrotum Labia minora Urethral meatus This guide gives a review of basic male anatomy and female anatomy. Many of the new knowledge in the field of abuse evaluation have been in normal prepubertal female anatomy. Posterior fourchette Fossa navicularis Glans Medius raphe Anus Perineum

Highlights: Gives a review of normal hymenal anatomy Highlights: Gives a review of normal hymenal anatomy Illustrations of common types of hymen Annular Crescentic Cribriform The many variations of “normal” are presented, including the different types of hymens, with clear illustrations.

Highlights: Anal examination now standard operating procedure Perianal Skin Folds (rugal folds) Anal Verge The conduct of anal examinations will now be considered standard operating procedure in medical examinations evaluating child abuse. Any injuries must be described, including location of injury.

Highlights: Update on Techniques of Genital Examination Measurement of the hymenal opening is unnecessary. Medical basis: Berenson, et al, “ Use of Hymenal Measurements in the Diagnosis of Previous Penetration, Pediatrics 109(2), 2002 Legal basis: Supreme Court Decision: People v. Baring, Jr. (GR No. 137933, January 8, 2002) This guide includes updates on the proper techniques in the conduct of the genital examination. for example, the measurement of the hymenal opening either visually or by inserting an object into the vaginal canal is now outmoded. The scientific and legal basis for such is provided.

Limits of Interpretation of Physical Findings in Child Sexual Abuse The diameter of the hymenal opening is highly undependable as a diagnostic criterion for abuse. “Most hymenal measurements lack adequate sensitivity or specificity to be used to confirm previous penetration” Abby Berenson, et al, Pediatrics Vol .109 No 2 Feb.2002

Highlights: Update on Techniques of Genital Examination Measurement of the hymenal opening is unnecessary. Legal basis: Supreme Court Decision: People v. Baring, Jr. (GR No. 137933, January 8, 2002) “Hence, insertion of a finger or foreign matter inside the hymenal opening under the pretext of determining abuse is unnecessary and inappropriate.” This guide includes updates on the proper techniques in the conduct of the genital examination. for example, the measurement of the hymenal opening either visually or by inserting an object into the vaginal canal is now outmoded. The scientific and legal basis for such is provided.

Highlights: Update on Techniques of Genital Examination Clear medical indications for speculum and internal examination of the prepubertal child are listed Suspicion of foreign body in vaginal canal Profuse vaginal bleeding (suggesting probable internal injury) Examination should be done under sedation or general anesthesia Similarly, IE and speculum examinations are now only to be done in the following circumstances: (READ THE SLIDE).

Working with abused children: some useful principles The process of investigating an allegation of abuse should not re-traumatize the child.

The Medical Examination for Allegations of Sexual Abuse

The Complete Medical Examination for Sexual Abuse Should include: Medical History General Physical Examination Multi-method Genital/ Anal Exam Use of magnification Specialized exam techniques Recording and Assessment of findings

Highlights: Adoption of a Uniform System of Classification of Findings Classification System for Impressions No evident injury at the time of examination Non-specific findings Suggestive of abuse Clear evidence of blunt force or penetrating trauma The Technical Working Group agreed that the classifications to be used for recording impression be based upon those found in Joyce Adams’ February 2001 Child Maltreatment publication, entitled “Evolution of a Classification Scale: Medical Evaluation of Suspected Child Abuse.” Medical findings are divided into four categories: Normal, Normal Variant or Nonspecific Finding, Suggestive of Abuse, and Clear Evidence of Blunt Force or Penetrating Trauma. This is a suggested system for classifying findings and will likely be revised in the future as more information becomes public concerning non-abused and abused children and adolescents.  

MAJOR REFERENCES Adams, J. “Medical Evaluation of Suspected Child Abuse.” Journal of Pediatric and Adolescent Gynecology 17(3), (June 2004): 191-197. Guidelines for Medico-Legal Care for Victims of Sexual Violence, Geneva, World Health Organization, 2003.

Highlights: Recognition of the limits of medical findings Medical basis: “Abnormal findings are not common in sexually abused girls…” Adams J, K Harper, S Knudson and J Rivilla. “Examination findings in legally confirmed child sexual abuse: it’s normal to be normal.” Pediatrics 94. (1994): 310-317. This guide reminds the doctor that normal or non-specific findings in a patient does not necessarily imply that no abuse occurred. In 1994, Adams, et al., launched a study to determine the frequency of abnormal findings in a population of children with legal confirmation of sexual abuse. In their review of 213 cases with perpetrator conviction for sexual abuse, 77 percent of these girls had normal or non-specific genital examination findings. As Adams notes:   “Abnormal findings are not common in sexually abused girls…More emphasis should be placed on documenting the child’s description of the molestation, and educating prosecutors that, for children alleging abuse, ‘It’s normal to be normal.’”   Further, the Supreme Court of the Philippines ruled in an en banc decision (People v. Llanita G.R. No. 134101, September 5, 2001) that “the absence of hymenal lacerations does not disprove sexual abuse.”

Highlights: Recognition of the limits of medical findings “…the absence of hymenal lacerations does not disprove sexual abuse…” Legal basis: Supreme Court Decision: People v. Llanita (GR No. 134101, September 5, 2001)

Interpretation of Physical Findings in Child Sexual Abuse Non-specific findings- findings that may be the result of sexual abuse depending on the timing of the examination with respect to the abuse, but which may also be due to other causes, or may be variants of normal

Interpretation of Physical Findings in Child Sexual Abuse Suggestive of abuse – findings that have been noted in children with documented abuse, and may be suggestive of abuse, but for which insufficient data exists to indicate that abuse is the only cause. History is crucial in determining overall significance.

Highlights: Controversial terms agreed upon “Notch” Angular or “V”-shaped indentation on the edge of the hymenal membrane and may extend to the muscular attachment of the hymen  ·    If notch is greater than 50 percent of the hymen’s diameter, classify as “suggestive of abuse.” ·    If notch fully transects the hymen, classify as “evidence of blunt force or penetrating trauma.” Hymen The technical working group agreed on the definitions of certain controversial terms. This has been one of the longer steps” in the process. The agreed upon definition of the notch and its implications are shown on the slide.

Highlights: Controversial terms agreed upon Narrowing of the Hymen (Attenuation) Attenuation Narrowing of the hymen (note: this term should be restricted to indicate a documented change in the width of the posterior portion of the hymen following an injury) Attenuation of narrowing of the hymen was another controversial term.

Interpretation of Physical Findings in Child Sexual Abuse Clear evidence of blunt force or penetrating trauma – Findings which have no explanation other than trauma to the hymen or perianal tissues

Definitive Findings in Child Sexual Abuse Presence of semen, sperm, or acid phosphatase Pregnancy Sexually transmitted diseases Gonorrhea Syphilis Chlamydia HIV Fresh genital or anal injuries Complete absence of hymen tissue down to the vaginal wall (Adams, 1993; Bays & Chadwick, 1993)

Limits of Interpretation of Physical Findings in Child Sexual Abuse Distribution of abnormal findings in sexually abused girls:

Limits of Interpretation of Physical Findings in Child Sexual Abuse Explanations for absence of findings: 1. Nothing happened. 2. Something happened which did not cause injury. 3. Something happened which may have caused an injury which has healed since the event occurred.

WHAT WE DON’T KNOW Exactly what object caused injury When it occurred (once injury has healed) How many times it happened Who did it (UNLESS THERE IS DNA EVIDENCE)

ISSUES WITH DNA Cost Collection of evidence at Crime Scene Storage of evidence

WHAT DO WE KNOW? Majority of children with history of SA have normal examinations Children’s injuries heal amazingly well

Question: Can a child get an STI by merely sharing the same bed, toilet seat , or towel with an infected individual? NO Except for infections acquired perinatally , presence of an STI in a child implies that it was transmitted by sexual contact

Questions: Can biking or horseback-riding cause hymenal injuries? NO How about dancing or doing the split? There is no evidence of anal or genital injuries associated with or resulting from the above vigorous physical activities.

Question: Can masturbation cause hymenal injuries? NO Normal masturbation in girls involves clitoral or labial stimulation.These do not cause hymenal injury. (Hobbs & Wynne 1987; Huffman, Dewhurst & Capraro, 1981; Tipton , 1989; Woodling & Kossoris, 1981)

Question: NO Can masturbation cause hymenal injuries? Study of self-injurious behavior in 97 mentally retarded individuals: No genital or anal injuries were reported (Hyman, Fisher, Mercugliano & Cataldo, 1990)

MEDICAL GENITAL EXAM = INVESTIGATION MOST IMPORTANT Statement of Child Police Investigation to Corroborate Story > collateral interviews > gather evidence at the site

The Bottom Line in Child Abuse Evaluation Don’t forget the jigsaw puzzle!

THANK YOU