Medical Forensic Response to Sexual Assault, Child Abuse, and other Forms of Interpersonal Violence: EMS

1. Medical Forensic Response to Sexual Assault, Child Abuse, and other Forms of Interpersonal Violence: EMS Barbara Haner, MN, ARNP Providence Intervention Center for Assault and Abuse

2. Objectives • Recognize red flags that may indicate child sexual and/or physical abuse • Recognize common offender behaviors associated with child sexual abuse • Implement treatment response consistent with mandatory reporting laws and district policy

3. Statistics • 1 in 4 girls, 1 in 6 boys will be assaulted before they graduate from high school • In Snohomish County, this means that of the over 70,000 girls and boys currently in middle and high school approximately 8000 girls and 6000 boys will be assaulted before they graduate • Less than 4% of teens will report

4. Statistics Continued • FBI stats indicate a 1-2% false report rate (other studies indicate 15%) • 80-90% of children are assaulted by a known family member or friend (trusted family friend/ S.O. of mother 56%, family members 36%, strangers 8%) • Non-familial abduction of children under 10 years usually results in fatality within 3 hours

5. Medical Forensic Response to Sexual Assault Variation of what your county response is (SANE, SART, SAFE) May be a “Team” or individual RNs that have been trained. May be regular ED RN. May have a CAC (Child Advocacy Center) with scheduled assessments with colposcopic examination

6. Advocacy Services • Every County has a designated SA (sexual assault) response center • 24-hour crisis line response • May have emergency room response • Information and support • Medical Advocacy • Will respond to your call • Information and referral • Case Management

7. Sexual Assault Advocates • RCW 70.125.060 makes provisions for victims to have a sexual assault advocate available to them throughout the investigative and legal process

8. Why Aren’t Child Sexual Assaults Reported • Fear of retaliation (esp with teens) • He loves me • Fear of negativity or personal disclosure associated with legal proceedings or CPS involvement • Cultural stigmatization (shame, guilt, SEX) • Child’s lack of competency and/or capacity • Lack of knowledge based language • Willingness to believe the offender over their child • Co-Dependent behavior by caregiver • Emotional • Housing • Financial

9. Why Go to the ED • Increased likelihood of reporting • Safe place to stash the victim • You don’t know what you don’t know • You never get the entire story the first time • Medical care • Limited time frame for forensics, ECP, Toxicology, ETOH • Advocacy support • Documentation of history, injuries • Third party reporting • Every victim of interpersonal violence should receive a medical exam • Assume that any possible child abuse includes sexual assault

10. Offender Epidemiology • Listen to the original facts • Don’t be swayed by the delivery • Usually no disclosure until he hurts someone • They want to give you a plausible reason to make you go away • They are master manipulators • Grooming behavior • Singles out type/age of victim • Gifts, secrets, special time/activities • Their behavior is often predictable • White knight saves the day (day care, housing, financial) • Encourages mom to work while he provides day care • What happens during evening activities

11. Common Injuries • Only 20% of confirmed SA will have visible medical findings. Usually fondling then masturbating. • Pre-pubescent • Vestibule: erythema, superficial tears in skin. May have ejaculate in belly button and folds of skin. • Post pubescent • Based on history of sexual activity • Very few serious or life threatening injuries

12. Forensics • Based on Locard’s Principle of Transference • Includes • History • Presentation • Injuries (medical findings) • Biological • Debris • Trace • Hair • Fibers

13. Forensic Considerations • Even if victim has showered/bathed and changed clothes there is good chance of DNA • Bring soiled clothes, blankets, hay bales, car seats, sanitary pads, condoms, tampons, diaphragms, diapers, sheets • Encourage victim to not eat, drink, defecate, douche, oral hygiene prior to examination • Save toilet tissue • Never place in plastic– always use paper bags first • Chain of Custody Documentation

14. Child Specific Forensic Considerations • In cases involving pre-verbal children, often the only chance for prosecution is the discovery of physical evidence • Most child SA does not include penetration, thus usually no evidence of injury • Most law enforcement and medical personnel are focused on the safety issue and forget the forensic portion

15. Child Forensic Considerations • Bring bedding, crib toys, soiled diaper pail, any clothing • Bring anything that the child may have come into contact with or may have laying on during or since the abuse • Diapers, wipes • Urine • Hair

16. Drug Endangered Children (DEC) • All children removed from a lab should receive immediate medical assessment regardless of lack of signs and symptoms • Usually decontamination occurs in the field • Limited time frame for testing (Meth clears in hours) • Standard testing will occur to check for blood disorders, liver damage, hair samples for long term exposure, toxicology screens • Children may be drug endangered without being exposed to manufacturing

17. Drug Facilitated Sexual Assault • Alcohol is most common drug (very important to determine in teens) • Tranquilizers and pain medication • Veterinary Drugs • Over the counter meds • Rohypnol and GHB not common in this area • The use of drugs to facilitate increases the degree of assault charged

18. EMS Response • Multidisciplinary approach • Collaboration • Preservation • Observation • Documentation • Coordinated County Protocols • 2000 county protocols were mandated by the Legislative body and are to be reviewed every 2 years

19. Collaboration • Immediate coordinated investigation • Law Enforcement • CPS • Medical Examiner • Victim Support Services • Emergency Department • Specialized medical care • Department of Health

20. Preservation • Preserve Life – Render Aid • Preserve/secure Scene • 1 path of entrance/exit • Disturb physical objects as little as possible • Don’t use any household objects • Don’t open doors/windows except as required • Contact police • Preserve Information • Who • When • Where • How

21. Observation • Be conscious of the environment • Odors • Damage • Housekeeping • Temperature/power/water • Windows/doors • Food • Presenting and on-going demeanor of those present • History provided • What initial aid was done • Photos if possible

22. Documentation • Make detailed notes as soon as possible • Discrepancies often make the case • Who said what • What did the child say, verbatim if possible • All possible evidence of injuries • Make a Timeline if possible • When was the child “normal” last • Initial symptoms “tell me about how the baby has been over the last 48-72 hours” • Who has been with the child during this time • Why did you call the aid car • Who is everybody, who’s missing

23. Medical Exception to Hearsay • Crawford Supreme Court Decision • Must include what you said or asked • Verbatim in quotes what the child said

24. What is Your District’s Policy • What can you do if someone signs a waiver and you want to take the child

27. 4 year old female ,physically and sexually abused by mom’s new husband Long history of meth use and manufacturing

31. Whatcom Co. SA Services • DV/SAS • 1407 Commercial; Bellingham, 98225 • 24 hour Hot line: 360-715-1563 1-888-715-1563 • Office line: 360-671-5714 • xx

32. PICAA Contacts • Barbara Haner (Medical): 425-297-5770 • Medical Appointments: 425-297-5776 • Consult with the NE : 425-258-9031 • Gayle Ossenkop (Manager): 425-297-5780 24 hour Advocacy Crisis Line 425-252-4800