Forensic evidence findings in prepubertal victims of sexual assault

Swedish child homicide investigations: A population-based study 1998 to 2017

BACKGROUND

Child homicide investigations are intricate, and the forensic examinations are of paramount importance in such cases. Despite this, the forensic profile of child homicides remains unexplored.

OBJECTIVE

Our objective was to provide an overview of the forensic aspects and investigational challenges in Swedish child homicide cases spanning from 1998 to 2017, with a specific focus on enhancing investigative methods.

PARTICIPANTS AND SETTING

70 cases with 82 victims (41 girls, 41 boys) aged between 0 and 14 were included.

METHOD

Police, crime scene and autopsy reports of solved Swedish child homicides were retrospectively reviewed.

RESULTS

On average, 3.5 cases (4.1 victims) occurred annually, primarily within families (79 %). Notably, the number of cases increased by 10 % during the latter half of the study period (2008-2017) compared to the initial decade (1998-2007). In nearly 29 % of instances, the perpetrators followed the homicides with their own suicides. A majority of child deaths (89 %) resulted from concentrated acts of violence, most frequently involving blunt or sharp force. Furthermore, 66 % of the homicides took place within the parental home. Adequate crime scene processing, including documentation and evidence collection, occurred in 74 % of cases. The investigation unveiled several complicating factors: 22 % of victims and 47 % of crime scenes displayed no obvious signs of violence. Moreover, offenders often made physical (27 %) and verbal (26 %) attempts to mislead investigators.

CONCLUSIONS

In conclusion, most child homicides are familial in nature and associated with investigational complexities that can lead to misdirection. This research may inform procedural recommendations for child homicide investigations, but further exploration is needed to better understand the forensic characteristics of suspicious child deaths.

Addressing sexual assault in Pakistan: Insights from an analysis of female survivors at Lahore General Hospital

BACKGROUND & OBJECTIVE

Rape is a severe kind of sexual violence that represents a significant violation of human rights. The objective was to investigate the demographic and clinical features of female survivors of sexual assault in Lahore, Pakistan.

METHOD

A retrospective study was conducted at the Department of Forensic Medicine of Lahore General Hospital, analysing records of female sexual assault survivors investigated by affiliated police stations from November 2020 to November 2022. Data were collected from medicolegal certificates and medical notes and analysed using SPSS software.

RESULT

282 female survivors reported to Lahore General Hospital's Forensic Medicine Department, aged 5-55 years, with a mean age of 22.74 ± 8.30. A significant proportion (50.4%) were aged 16-25 years. Most survivors were examined between 6 and 24 h (34%) and 2-7 days (37.9%) after the assault, with the majority (95%) exhibiting well-developed secondary sexual characteristics. Sexual assault and physical abuse were both reported in 56.4% of cases. In 77% of cases, the perpetrator was known, and in 36.5% of cases, a weapon was used. No external body injury was observed in 74.8% of cases, and 2.8% showed signs of fresh hymen rupture. The study identified 92.2% of cases lost to follow-up.

CONCLUSION

This study highlights the pressing need to implement effective measures to prevent and address rape in Pakistan. The findings emphasise the need for education, improved forensic infrastructure and policy reforms to address sexual assault effectively.

The optimal timing of forensic evidence collection following paediatric sexual assault

BACKGROUND

Forensic evidence collection following sexual assault has an important medico-legal role. Despite the advent of DNA profiling, research into the optimisation of forensic biological specimen collection is limited. This has led to inconsistent and variable guidelines for forensic evidence collection. The guidelines in this jurisdiction (Victoria, Australia) recommends that specimens be collected up to 7 days following sexual assault in some circumstances. The aims of this study were to determine the optimal times post sexual assault for the collection of forensic biological evidence in paediatric cases (aged 0-17 years).

METHODS

A retrospective review of paediatric sexual assault cases seen by the Victorian Forensic Paediatric Medical Service (VFPMS) between 1 January 2009, and 1 May 2016, was undertaken. Specimen site and collection times post assault were collated from VFPMS medico-legal reports and compared with the forensic evidence analysis results reported by the Victoria Police, Forensic Services Department. In addition, a survey of recommended forensic specimen collection times post assault in the different Australian jurisdictions was undertaken for comparison.

RESULTS

Within the 6 year 5 month period studied there were 122 cases consisting of 562 different forensic specimens that were collected and analysed. 62 (51%) of cases produced one or more positive forensic result and, of the 562 specimens collected, 153 (27%) were positive for one or more of foreign DNA, spermatozoa, semen or saliva. Foreign DNA was more likely to be found if forensic specimens were collected during the first 24 h after the assault as compared with those collected at 25-48 h, (p < 0.005). Similarly, spermatozoa were identified more frequently on swabs collected at 0-24 h compared to 25-48 h (p < 0.002). Foreign DNA was not identified beyond 48 h post assault and spermatozoa were not identified beyond 36 h. Saliva and semen were not identified beyond 24 h. The youngest victims with positive forensic evidence were 2-3 years old. The survey of current forensic specimen collection practice in Australia shows that the guidelines for timing of forensic evidence collection in child sexual assault cases is highly variable between jurisdictions.

CONCLUSIONS

Our results highlight the importance of collecting forensic specimens as a matter of urgency, regardless of age, within the first 48 h post assault. Although there is need for further research, the findings indicate a need for the re-evaluation of current guidelines for specimen collection in paediatric sexual assault cases.

Pediatric Forensic Analysis: The Benefits of DNA Collection Beyond 24 Hours

BACKGROUND

Although the presence of forensic evidence aids in successful prosecution of sexual abuse, controversy remains regarding the timing and indications for collection of forensic evidence in child sexual abuse/assault.

OBJECTIVE

The purpose of this study was to describe forensic evidence findings in acute child sexual abuse after implementing more inclusive indications for collection of evidence in a pediatric emergency department and to identify factors associated with yield of DNA.

RESULTS

Of the 306 evidence kits collected and analyzed, 110 (35.9%) kits were positive for an interpretable DNA profile foreign to the patient, which may or may not have contributed to the investigation of the sexual abuse concern. Several factors were associated with increased forensic yield of identifiable foreign DNA: increased age of child victim, 48 hours or less between the latest incident of sexual abuse and the collection of forensic evidence, child disclosure of high-severity sexual abuse acts (anal-genital or genital-genital contact) in the pediatric emergency department forensic interview, and sexual abuse by a nonrelative perpetrator.

CONCLUSIONS

Finally, although certain factors were associated with increased yield of identifiable foreign DNA within each factor, there were multiple outliers where failure to collect forensic evidence would have resulted in a loss of recoverable foreign DNA.

A multidisciplinary approach in pre-pubertal child sexual assault cases - forensic evaluation and suggestions

BACKGROUND

Child sexual assault is highly prevalent in India yet a handful cases are reported under POCSO (Protection against child sexual offenses) Act, 2012. Even though the victims' testimony alone is enough to arrest accused as regulated by the Supreme Court but forensic evidence is still critical for sentencing rapists. A systematic evaluation of such cases will estimate impact of Child sexual assault (CSA) and pinpoint important aspects required for progression of prevention strategies and provision of support.

METHOD AND OBJECTIVE

Present study reviewed cases pertaining pre-pubertal victims (up to 10 years age). Study included simple descriptive analysis of data highlighting significance of different variables in sexual assault cases involving child victims- perpetration, interventions, medical examination and forensic DNA analysis with the aim to improve primary preventive strategies and identify potential setbacks obstructing road to justice.

RESULT

The strengths and weaknesses of pre-pubertal sexual assault assessment were identified. This study analyzed socio-economic backgrounds, age of alleged accused and whether known to the victim. Frequently reported type of abuse was assessed and total reviewed cases that yielded DNA profile from exhibits of victims and alleged accused were determined.

CONCLUSION

As emerged in present study, pre-pubertal CSA is a complicated phenomenon grounded in interplay between societal influences, family support, evidence collection, legal delays, and medical hindrances that greatly affect DNA analysis. Prevalence of CSA is evidently alarming and demands stringent measures to be taken to prevent and control it. Joint and multidisciplinary assessment is important for forensic reporting rather than solo assessment.

Medico-legal evidence collection in child sexual assault cases: a forensic significance

Background

Every year, millions of children face sexual exploitation worldwide. In India, 109 children (National Crime Records Bureau2018) were sexually abused everyday (22% jump from the previous year). Even with advanced DNA techniques, the conviction rate remains low. The methods used for forensic DNA evidence analysis vary around the world, but the primary step of biological evidence collection plays the most vital role. Proper and timely evidence collection from the victim by a trained medical professional is important.

Main body

Dynamics of child sexual assault being massively different from an adult rape demands altogether different approach of evidence collection. A standard sexual kit employed for evidence collection needs urgent modifications considering genital development of pre- and post-pubertal victims. In the present study, parameters including systemic collection and evaluation of forensic evidences, medico-legal examination, and developmental consequences of sexual assault on pre-pubertal victims were assessed. Further suggestions for separate evidence collection kit during medico-legal examination were given for pre-pubertal victims and alleged accused in sexual assault cases in order to streamline and for better evaluation of DNA analysis in forensic laboratories.

Conclusion

The importance of expert medical practitioners plays a significant role in collection of appropriate information and evidences from the victim of sexual assault. General guidelines for evidence collection in sexual assault cases are not well suited for pre-pubertal victims. Appropriate reforms pertaining to the age and genital development of victims are required. Securing clothing as forensic evidence is essential in most cases as it turned out to be the exclusive evidence bearing material. The purpose of this article is to bring awareness about the thorough medical examination and modified sexual assault kit for pre-pubertal victims and alleged accused for a better approach in evidence collection and conviction rate.

Persistence of Semen on five different fabric types in various water environments

Evidence collected from biological fluids obtained from a crime scene is essentially important in forensic cases. A potential profile can be generated from these obtained samples and this can help in identifying the victims and/or suspects of sexual assault. The water environments selected for this study are all related to the potential crime scenes from which there is a possibility of finding a dead body or clothing of a sexual assault victim. Tap water, River water, Swimming pool water, and Canal water were selected. Fabric types selected were khaddar, linen, silk, polyester, and chiffon. Detection of seminal stains was carried out by three methods; Alternate Light Source (ALS), Acid phosphatase (AP) testing, and Kernechtrot-Picro-indigo-carmine (KPIC) testing. These tests were performed for each fabric type in each water environment after regular intervals, 24 h, 48 h, 72 h, 4 days, 7 days, and 14 days. This study aimed to compare the ability of five types of fabrics to retain seminal material after immersion in four different types of water environments. Fluorescence was only detected in tap water-soaked silk fabric after 14 days of immersion. Seminal fluid was detected in khaddar, chiffon, silk, and polyester in samples immersed for 14 days in tap water. Spermatozoa were retained by khaddar and silk immersed in tap water, Polyester fabric in tap and river water, Chiffon in only river water and Linen in swimming pool water when immersed for 14 days. However, fluorescence, seminal fluid or spermatozoa were not detected in linen fabric regardless of all the afore mentioned variables.

Forensic medical results and law enforcement actions following sexual assault: A comparison of child, adolescent and adult cases

BACKGROUND

In sexual assault cases, little research has examined differences in forensic medical findings and law enforcement response by victim age across the entire age range.

OBJECTIVE

This study addressed this gap by comparing four victim age groups: adults, adolescents over the age of consent, adolescents under the age of consent, and children under 12.

PARTICIPANTS AND SETTING

Cases were randomly sampled from a statewide database of medical reports on sexual assault examinations conducted in hospital emergency departments, including only cases reported to law enforcement (N = 563).

METHODS

Data were combined from a medical report database, from coding of medical documentation and crime laboratory reports, and from case data provided by law enforcement.

RESULTS

Rates for both younger and older adolescent victims and adult victims were comparable, with no statistically significant differences on most variables: penetration, perpetrator use of force, non-genital and genital injuries, presence of biological evidence, generating assailant DNA profiles, DNA match to suspect, hits in the FBI's DNA database, and law enforcement unfounding (i.e., determining allegations to be false or baseless). Child victims were significantly less likely to have a non-genital injury, and their cases were significantly more likely to be founded by law enforcement. Arrests were significantly more likely when victims were under the age of consent.

CONCLUSIONS

Despite significant differences by victim age, similarity between adolescent and adult cases was substantial. Both younger and older adolescents may be at higher risk of physical violence during sexual assault than previously recognized, and need greater attention in response systems.

Child sexual abuse: The significance of the history and testifying on non-confirmatory findings

BACKGROUND

Despite numerous studies and publications, there is still a common expectation that a medical assessment can confirm or rule out child sexual abuse (CSA). The truth is that CSA can never be ruled out and can seldom be confirmed on clinical grounds.

AIM

The objective of this article was to suggest which aspects to consider when the expert medical witness in a CSA case needs to explain why CSA can seldom be confirmed and can never be ruled out. The importance of a sound medical and medico-legal history was discussed because the history was generally the only positive 'finding' of the assessment of children who have possibly been abused.

METHOD

Authoritative sources were used to support the explanation of reasons for an absence of corroborative clinical findings in CSA, as defined by the World Health Organization. The authors structured the individual sections by providing a background on which to base the testimony. They then summarised the clinical forensic significance of the information which should be offered in the courts and which should reflect on the court records, to be taken into account in the eventual decision, which will be made by the court.

RESULTS

A guideline was provided for answering questions frequently posed to the expert witness in child abuse cases where there were no positive findings.

CONCLUSION

A structure for the explanation of reasons for a normal clinical examination when evaluating children who may have been sexually abused may reduce the discomfort of medical witnesses and improve the quality of expert medical testimony.

Child Abuse and Conditions That Mimic It

One percent to 2% of children in the United States are confirmed victims of child abuse, with many more likely affected. It can be difficult to diagnose, with often misleading medical histories, but acute care providers should be aware of its presenting warning signs and how to evaluate and document suspicious physical findings. Young children who cannot disclose are most vulnerable to forms of abuse with high morbidity and mortality, so it is important to keep it in the differential diagnosis and to be aware of and know how to rule out medical conditions that mimic abuse.

Clinical characteristic and risk factors of recurrent sexual abuse and delayed reported sexual abuse in childhood

Child sexual abuse (CSA) is a global problem that affects children of all ages, and the evaluation of these victims by psychologic and gynecologic experts in pediatric emergency departments is an important issue. Few data are available on the characteristics of children admitted to pediatric emergency department with recurrent CSA and delayed reported CSA. The aim of the present study was to describe the clinical features of, and risk factors for, recurrent CSA and delayed reported CSA. The study retrospectively analyzed victims of CSA who were admitted to a pediatric emergency department. Chi-square tests and univariate analyses were performed to assess the risk factors of recurrent or delayed reported CSA. Of the 91 CSA cases, 32 (35.2%) were recurrent assaults. Of the 70 cases recorded the duration of the event, 22 (31.4%) were delayed report cases. Comparisons of the non-recurrent and recurrent CSA assault groups revealed a significant increase in comorbidities (odds ratio [OR]: 4.46, 95% confidence interval [CI]: 1.54-12.93), acute psychiatric problems (OR: 3.18, CI: 1.26-8.06), attempted suicide (OR: 4.23, CI: 1.28-13.99), and the need for treatment with antipsychotic medications (OR: 5.57, CI: 1.37-22.65). Compared with non-delayed reported cases, the delay reported cases of CSA were significantly more likely to have anxiety (P < .05). The CSA victims in the present study exhibited acute medical and/or psychosocial problems, which indicate that pediatric emergency professionals have a responsibility to look for and recognize particular characteristics in these victims.

Medical Evaluations Then and Now

The role of medicine for children suspected of having been sexually abused has advanced significantly since the 1980s. Newer tests such as DNA and nucleic acid amplification have added to the detection of perpetrators and disease, respectively. Non-acute examination physical findings are seen in only 5% to 10% of instances. Physical findings regarding the hymen and anus have been found to often be normal variants-findings that some used to regard as signs of sexual abuse. Newer considerations for clinicians include Internet child pornography, human trafficking, and use of video/photographic recording. New technologies such as high definition digital photography and telemedicine help to document abuse in a much improved way than existed several decades ago. Nevertheless, the basic approach of careful history-taking remains a bedrock for the diagnosis of child sexual abuse.

Prepubertal Vaginal Bleeding: Etiology, Diagnostic Approach, and Management

IMPORTANCE

Prepubertal vaginal bleeding outside the neonatal period is always abnormal and is very alarming to parents. A variety of practitioners, including obstetrician-gynecologists and pediatricians, may be asked to see patients with this presenting complaint, yet many do not receive adequate training in pediatric gynecology.

EVIDENCE ACQUISITION

Review of the published literature in PubMed, focusing on the last 20 years, regarding the incidence, etiologies, diagnosis, and management strategies for the common causes of prepubertal vaginal bleeding.

RESULTS

Careful history taking and pediatric-specific gynecological examination skills, including awareness of normal anatomy across the age spectrum and the ability to identify an estrogenized hymen, are keys to the appropriate assessment of this clinical problem.

CONCLUSIONS AND RELEVANCE

Prepubertal vaginal bleeding has many causes and requires a thorough targeted history and pediatric genitourinary examination, requiring knowledge of the variants of normal pediatric genitourinary anatomy. Most causes can be easily treated and are less likely to be due to sexual abuse or malignancy.

Acute Sexual Assault in the Pediatric and Adolescent Population

Children and adolescents are at high risk for sexual assault. Early medical and mental health evaluation by professionals with advanced training in sexual victimization is imperative to assure appropriate assessment, forensic evidence collection, and follow-up. Moreover, continued research and outreach programs are needed for the development of preventative strategies that focus on this vulnerable population. In this review we highlight key concepts for assessment and include a discussion of risk factors, disclosure, sequelae, follow-up, and prevention.

Gender Differences In Extrafamilial Sexual Abuse Experiences Among Young Teens

Extrafamilial sexual abuse experiences of young adolescents (ages 10–14), particularly young teen boys, are not well studied. This retrospective chart review study compared psychosocial correlates and victimization experiences between young adolescent girls ( n = 226) and boys ( n = 64) referred to a hospital child advocacy center. Several differences in risk behaviors and abuse experiences were found: Girls were more likely to have run away, to be truant from school, to report substance use, to have multiple perpetrators, and to have physical findings from the abuse. Boys were more likely to have a diagnosis of attention deficit disorder and to report anal penetration, and rarely disclosed abuse at the time of the incident. Peers were girls’ most common choice for disclosing abuse, whereas boys confided most often in their mothers or other adults. These findings suggest sexually abused young adolescent girls and boys need distinct, developmentally appropriate screening and care in school and health care settings.

Helpfulness of rectoanal endosonography in diagnosis of sexual abuse in a child

BACKGROUND

Clinical importance of sexual abuse in children has rapidly expanded in recent years, but despite of it, the lack of medical signs in the vast majority of sexual abuse cases, makes it difficult to assess. Given that, owing to our prior experience in endosonography (EUS) of the anal canal in child with anorectal malformations, we wanted to test EUS as a diagnostic method of sexual abuse in a child.

PURPOSE

The purpose of our study is to present our experience in the use of anorectal EUS among children with suspected sexual abuse.

MATERIALS/METHODS

We present 40 consecutive patients (34 boys and 6 girls, age: 10months-13years) recruited from April 2010 to December 2012, with suspected sexual abuse those made a transrectal EUS.

RESULTS

The procedure was well-tolerated in all patients without complications. Rectoanal EUS findings were normal in 27 patients and showed a partial interruption in the external anal sphincter in 8, scars in 2, double rail image in 2, and rectal wall hematoma in 1.

CONCLUSIONS

The interpretation of findings in children depends of historical, physical, and laboratory findings. We believe that anal EUS is another aid in the constellation of clinical factors that could help in diagnostic of sexual abuse.

DNA transfer during laundering may yield complete genetic profiles

In a number of child sexual abuse cases, the alleged perpetrator is a member of the nuclear family. In those cases, there is a possibility that the suspect's DNA was innocently deposited onto the child's clothing without acts of sexual assault ever occurring, for example via secondary transfer within the washing machine. To assess the quantity and quality of DNA that may be transferred among clothing during laundering, we conducted three series of experiments. First, we evaluated the level of spermatozoa that may be transferred by washing pristine pairs of underwear with bed sheets containing a varying number of ejaculates. Secondly, we explored whether current genetic methods may also detect the transfer of DNA from vaginal secretions during a machine wash. Finally, we analyzed the background levels of DNA on children's underwear collected from control families where sexual abuse never occurred. For both spermatozoa and vaginal secretions, we revealed that sufficient amounts of DNA may transfer onto laundered clothing to yield complete genetic profiles. Furthermore, DNA from relatives living within the same household was found in most cuttings taken from control children's underwear. Based on these findings, we present a framework for the handling and interpretation of intrafamilial sexual abuse cases. These suggestions should help determine whether DNA was deposited directly onto a fabric or merely transferred during a wash.

Perceptions of credibility of sexual abuse victims across generations

The success of prosecutions of perpetrators of sexual abuse often depends substantially upon the perceived credibility of the victim witness. However, perceptions of credibility may vary by generation of the observer, and the constitution of juries may therefore lead to bias. In this study we examined whether perceptions of credibility of female victims of sexual abuse varied across generation Y, generation X, "baby boomers", and "builders". One hundred and twenty-eight jury-eligible members of the community from each generation (N=512) responded to ten questions assessing the perceived believability, competence, trustworthiness, demeanour and sexual naiveté of females providing testimony related to alleged sexual abuse. Although consistent between-generation differences were not found for all questions, or all four groups of generational cohorts, in instances where significant differences were found, it was consistently the older generation groups (builders and baby boomers) that attributed less credibility to the victim than the younger generation groups (generation Y and generation X). The implications of these findings are discussed.

Validation of a combined autosomal/Y-chromosomal STR approach for analyzing typical biological stains in sexual-assault cases

DNA testing is an established part of the investigation and prosecution of sexual assault. The primary purpose of DNA evidence is to identify a suspect and/or to demonstrate sexual contact. However, due to highly uneven proportions of female and male DNA in typical stains, routine autosomal analysis often fails to detect the DNA of the assailant. To evaluate the forensic efficiency of the combined application of autosomal and Y-chromosomal short tandem repeat (STR) markers, we present a large retrospective casework study of probative evidence collected in sexual-assault cases. We investigated up to 39 STR markers by testing combinations of the 16-locus NGMSElect kit with both the 23-locus PowerPlex Y23 and the 17-locus Yfiler kit. Using this dual approach we analyzed DNA extracts from 2077 biological stains collected in 287 cases over 30 months. To assess the outcome of the combined approach in comparison to stand-alone autosomal analysis we evaluated informative DNA profiles. Our investigation revealed that Y-STR analysis added up to 21% additional, highly informative (complete, single-source) profiles to the set of reportable autosomal STR profiles for typical stains collected in sexual-assault cases. Detection of multiple male contributors was approximately three times more likely with Y-chromosomal profiling than with autosomal STR profiling. In summary, 1/10 cases would have remained inconclusive (and could have been dismissed) if Y-STR analysis had been omitted from DNA profiling in sexual-assault cases.

ACUTE PELVIC PAIN IN THE ADOLESCENT: A CASE REPORT

Diagnosis and treatment of acute pelvic pain in the adolescent female requires differentiating among a broad differential diagnosis that includes potentially serious illness across several organ systems. The case presented provides an illustration of the assessment and management of acute pelvic pain, and key teaching points about important potential causes.

Is fluorescence under an alternate light source sufficient to accurately diagnose subclinical bruising?

This single-blinded, randomized validation study was conducted to evaluate whether fluorescence under alternate light sources (ALS) is sufficient to diagnose subclinical bruising (bruising not visible under white light). Standardized trauma was induced on randomly selected ventral forearms. On days 1, 7, and 14 investigators independently examined case forearms under white light for perceived bruising and under ALS for fluorescence and compared body maps. 56 case and 62 control forearms (n = 118) were examined. Sensitivity of ALS on days 1, 7, and 14 was 76.8%, 69.6%, and 60.7%, respectively, compared to 69.6%, 60.0%, and 32.1% for white light. The specificity of ALS on days 1, 7, and 14 was 51.6%, 59.7%, and 53.2%, respectively, compared to 71.0%, 81.4%, and 86.9% for white light. ALS has increased sensitivity yet low specificity compared to white light in accurately detecting bruises. Fluorescence under ALS is not sufficient to accurately or responsibly diagnose subclinical bruising.

Forensic medical evaluations of child maltreatment: a proposed research agenda

Physicians play an important role in the forensic evaluation of suspected child abuse and neglect. There has been considerable progress in the medical field, helping distinguish findings related to maltreatment from other conditions or circumstances. Nevertheless, important questions remain. This article covers several of these questions and proposes a research agenda concerning five main topics: sexual abuse, neglect, fractures, abusive head trauma, and physicians work in interdisciplinary settings. The suggestions are hardly inclusive, but offer suggestions the authors think are priorities, and ones that research could reasonably address. By providing some background to gaps in our knowledge, this paper should be of interest to a broader audience than just medical professionals.

The influence of medical and behavioral evidence on conviction rates in cases of child sexual abuse

Child sexual abuse cases have one of the lowest conviction rates across all charges. While research has investigated the impact of attitudes and beliefs in judicial decision makers, little is known about the influence of medical evidence. The aim of this study was to examine how the presence or absence of evidence impacts on conviction. A sample of 113 child sexual abuse cases from Australia were coded for the types of evidence that were presented as well as other relevant descriptive data. The most significant predictor of verdict was the behavior of the child rather than the presence of medical evidence. This finding suggests that greater attention might be given to the collection and reporting of this evidence in future trials.

The evaluation of children in the primary care setting when sexual abuse is suspected

This clinical report updates a 2005 report from the American Academy of Pediatrics on the evaluation of sexual abuse in children. The medical assessment of suspected child sexual abuse should include obtaining a history, performing a physical examination, and obtaining appropriate laboratory tests. The role of the physician includes determining the need to report suspected sexual abuse; assessing the physical, emotional, and behavioral consequences of sexual abuse; providing information to parents about how to support their child; and coordinating with other professionals to provide comprehensive treatment and follow-up of children exposed to child sexual abuse.

Pediatric sexual assault nurse examiner care: trace forensic evidence, ano-genital injury, and judicial outcomes

INTRODUCTION

Although pediatric sexual assault nurse examiners (P-SANEs) have been providing care for over two decades there remain major gaps in the literature describing the quality of P-SANE care and legal outcomes associated with their cases. The purpose of this study was to compare quality indicators of care in a pediatric emergency department (PED) before and after the implementation of a P-SANE program described in terms of trace forensic evidence yield, identification of perpetrator DNA, and judicial outcomes in pediatric acute sexual assault.

METHOD

A retrospective review of medical and legal records of all patients presenting to the PED at Nationwide Children's Hospital with concerns of acute sexual abuse/assault requiring forensic evidence collection from 1/1/04 to 12/31/07 was conducted.

FINDINGS

Detection and documentation of ano-genital injury, evaluation and documentation of pregnancy status, and testing for N. gonorrhea and C. trachomatis was significantly improved since implementation of the P-SANE Program compared to the historical control.

DISCUSSION

The addition of a P-SANE to the emergency department (ED) provider team improved the quality of care to child/adolescent victims of acute sexual abuse/assault.

A case of a serial sexual offender: The first ever report from Turkey

There have been cases of serial sexual offenders and studies dealing with such cases in the literature. However, no serial sexual offender case was reported in Turkey, to the best of our knowledge. In this article, as the first report from Turkey, we present a serial sexual offender who assaulted 27 women. The assailant entered a total of 29 houses, and assaulted victims in 27 of them, and he failed to assault two individuals. The 'modus operandi' of the offender was identical in all assault cases and led the police towards a hypothesis that these assaults were all committed by the same individual. The offender did not admit the assaults and strictly refused a forensic psychiatric examination. Being an individual with a high level of education, having a respected position and profession, choosing women aged older than 18 years as victims were among distinctive features of the presented offender.

The sexual abuse of female children in Hungary: 20 years' experience

INTRODUCTION

The purpose of this study is to describe the characteristics of female children who experience sexual abuse and explore common features that may assist in developing prevention strategies.

MATERIALS AND METHODS

Between 1990 and 2010, 266 girls under the age of 18 years, suspected of being sexually abused, visited the Department of Adolescent Gynecology. We retrospectively collected data illustrating the features of all cases. Seventy-eight percent of the victims were primary school students, and 45% of them were between 11 and 14 years of age.

RESULTS

The perpetrator knew the victim in 67% of the cases and was a stranger in 33%. Seventy-five (28%) perpetrators were members of the victims' families. In 14% of cases, the perpetrator was the victim's father and in 9% her stepfather. The abuse had occurred on multiple occasions in 29% of the cases. The occurrence rate of abuse was highest in the summer season (54%). As much as 63% of children experienced vaginal penetration, while 37% experienced a variety of sexual contact that did not involve penetration. Eighty-five victims were physically injured, and in 40 cases the presence of sperm was confirmed in vulvo-vaginal smears. A high proportion of female child sexual abuse takes place within the family and is revealed only after multiple episodes. The true prevalence of sexual abuse is being appreciated now that Hungarian law and society have recognized this societal problem.

CONCLUSION

Prevention requires a systematic and lifelong approach to educating children about personal space and privacy and is the responsibility of parents and professionals.

Sexual abuse

Child sexual abuse is a common pediatric problem that concerns all pediatric health care providers. Management of child sexual abuse is multifaceted and multidisciplinary. Specialized health providers can provide consultation, but this availability does not minimize the role of the referring physician who often has ongoing contact with the family. Physicians are mandated to report cases of suspected or confirmed sexual abuse. In the majority of cases, a child’s statement about sexual abuse is the strongest evidence that abuse has occurred. Physical examination is normal in the majority of sexual abuse victims. Accurate, evidence-based interpretation of physical and laboratory findings is essential. Normal examinations, normal variants, and findings indicative of sexual contact must be differentiated. Forensic evidence collection and prophylactic treatments may be indicated when patients present within 72 hours of an abusive episode, and patients should be triaged accordingly. Potentially negative psychosocial outcomes should be addressed for patients and their families on initial evaluation and follow-up.

Forensic nurses' experiences of receiving child abuse disclosures

PURPOSE

A child's self-disclosure of abuse is a critical component in initiating intervention to stop abuse and decrease the likelihood of long-term negative outcomes. This study described the context in which child abuse victims disclosed to forensic nurses.

DESIGN AND METHODS

Thirty interviews were conducted at the International Forensic Nurses Scientific Assembly 2007 and then analyzed using narrative inquiry methodology.

RESULTS

Five themes emerged: child-friendly environment, building rapport, engaged listening, believing unconditionally, and the potential for false disclosures.

PRACTICE IMPLICATIONS

  Nurses can provide an environment that allows a child the perception of limitless time to share their unique stories.

Hymenal characteristics in girls with and without a history of sexual abuse

This article reviews the recent literature on physical findings related to the hymen in pubertal and prepubertal girls with and without a history of sexual abuse. Characteristics of normal hymenal anatomy, acute traumatic findings, and characteristics of healed trauma are discussed, particularly with regard to changes in the interpretation of these findings that have occurred over time.

Timing of the medical examination

The medical examination of the sexually abused child may have evidentiary, medical, and therapeutic purposes, and the timing of the examination requires consideration of each of these objectives. In cases of acute sexual assault, emergent examinations may be needed to identify injury, collect forensic evidence, and provide infection and pregnancy prophylaxis. Alternately, most sexually abused children are not identified immediately after assault, and the timing of the examination needs to balance physical and emotional issues with the availability of qualified examiners. In all cases, the best interests of the child should be paramount.

Forensic evidence collection and DNA identification in acute child sexual assault

OBJECTIVE

To describe forensic evidence findings and reevaluate previous recommendations with respect to timing of evidence collection in acute child sexual assault and to identify factors associated with yield of DNA.

METHODS

This was a retrospective review of medical and legal records of patients aged 0 to 20 years who required forensic evidence collection.

RESULTS

Ninety-seven of 388 (25%) processed evidence-collection kits were positive and 63 (65%) of them produced identifiable DNA. There were 20 positive samples obtained from children younger than 10 years; 17 of these samples were obtained from children seen within 24 hours of the assault. Three children had positive body samples beyond 24 hours after the assault, including 1 child positive for salivary amylase in the underwear and on the thighs 54 hours after the assault. DNA was found in 11 children aged younger than 10 years, including the child seen 54 hours after the assault. Collection of evidence within 24 hours of the assault was identified as an independent predictor of DNA detection.

CONCLUSIONS

Identifiable DNA was collected from a child's body despite cases in which: evidence collection was performed >24 hours beyond the assault; the child had a normal/nonacute anogenital examination; there was no reported history of ejaculation; and the victim had bathed and/or changed clothes before evidence collection. Failure to conduct evidence collection on prepubertal children beyond 24 hours after the assault will result in rare missed opportunities to identify forensic evidence, including identification of DNA.

Development of a screening tool for pediatric sexual assault may reduce emergency-department visits

OBJECTIVE

To define the characteristics of a novel screening tool used to identify which prepubertal children should potentially receive an initial evaluation for alleged sexual assault in a nonemergent setting.

METHODS

Electronic medical records were retrospectively reviewed from 2007 to 2008. Visits with a chief complaint or diagnosis of alleged sexual assault for patients aged 12 years or younger were identified. Complete records, those with no evaluation before pediatric emergency-department arrival, and those with child advocacy center follow-up were included. Records were reviewed to answer the following: (1) Did the incident occur in the past 72 hours, and was there oral or genital to genital/anal contact? (2) Was genital or rectal pain, bleeding, discharge, or injury present? (3) Was there concern for the child's safety? (4) Was an unrelated emergency medical condition present? An affirmative response to any of the questions was considered a positive screen (warranting immediate evaluation); all others were considered negative screens. Those who had positive physical examination findings of anogenital trauma or infection, a change in custody, or an emergency medical condition were defined as high risk (having a positive outcome).

RESULTS

A total of 163 cases met study criteria; 90 of 163 (55%) patients had positive screens and 73 of 163 (45%) had negative screens. No patients with negative screens were classified as high risk. The screening tool has sensitivity of 100% (95% confidence interval: 93.5-100.0).

CONCLUSIONS

This screening tool may be effective for determining which children do not require emergency-department evaluation for alleged sexual assault.

Collection of forensic evidence from pediatric victims of sexual assault

OBJECTIVE

To determine the time period after sexual assault of a child that specimens may yield evidence using DNA amplification. Secondary questions included the comparative laboratory yields of body swabs versus other specimens, and the correlation between physical findings and laboratory results.

PATIENTS AND METHODS

Data from evidence-collection kits from children 13 years and younger were reviewed. Kits were screened for evidence using traditional methods, and DNA testing was performed for positive specimens. Laboratory data were compared with historical information.

RESULTS

There were 277 evidence-collection kits analyzed; 151 were collected from children younger than 10; 222 kits (80%) had 1 or more positive laboratory screening test, of which 56 (20%) tested positive by DNA. The time interval to collection was <24 hours for 30 of the 56 positive kits (68% positives with a documented time interval), and 24 (43% of all positive kits) were positive only by nonbody specimens. The majority of children with DNA were aged 10 or older, but kits from 14 children younger than 10 also had a positive DNA result, of which 5 were positive by a body swab collected between 7 and 95 hours after assault. Although body swabs were important sources of evidence for older children, they were significantly less likely than nonbody specimens to yield DNA among children younger than 10 (P = .002). There was no correlation between physical findings and laboratory evidence.

CONCLUSIONS

Body samples should be considered for children beyond 24 hours after assault, although the yield is limited. Physical examination findings do not predict yield of forensic laboratory tests.

Forensic issues in the assessment of sexually assaulted adolescents

This article provides a general overview of the principles of conducting a forensic evaluation of adolescents who have been exposed to sexual abuse. This problem is common and is associated with a large burden of suffering. There is a strong likelihood that most paediatricians will be called on to perform such evaluations at some point in time. This overview includes a description of the forensic examination, focuses on such issues as consent and contact with child protection services, and provides specific guidelines about interviewing the adolescent. Familiarity with how to conduct a forensic evaluation will hopefully improve the availability of this service for adolescents. Contact with the legal profession can be stressful. At the same time, paediatricians are in a unique position to advocate on behalf of their adolescent patients.

The role of the medical provider in the evaluation of sexually abused children and adolescents

It was only 30 years ago that the medical community began to develop an increased awareness of child sexual abuse, and the role of the medical provider in the evaluation of sexually abused children has evolved significantly. As clinicians worldwide develop a greater understanding of the impact of the sexual abuse evaluation on the child, the roles of the physician and nurse have changed. In the United States, current practice often uses a multidisciplinary assessment involving skilled forensic interviewing of the child and a medical examination done by a medical provider with specialized training in sexual abuse. In order to minimize child interviews, these assessments are frequently held in settings such as child advocacy centers, where forensic interviewers and medical clinicians, child protective service workers, and police and district attorneys can work jointly to address the legal and protective issues in a coordinated fashion.

Perceptions of child sexual abuse-a qualitative interview study with representatives of the socio-legal system in urban Tanzania

Through in-depth interviews, this study explored perceptions and experiences of key players handling child sexual offense cases in Dar es Salaam, Tanzania. The informants included public police investigators, magistrates, legal workers, and social workers working with nongovernmental organizations. The interviews were recorded, transcribed verbatim, and analyzed using qualitative content analysis. Five themes emerged summarizing factors associated with sexual offenses, including community passivity, legal system weaknesses, legal framework inadequacy, and key players' vulnerabilities. Addressing the identified weaknesses may promote justice, while changes in attitudes and norms are needed for the prevention of sexual offenses to children.