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Child Sexual Abuse: Overcoming Society’s Perceptions

Child Sexual Abuse: Overcoming Society’s Perceptions . Texas Association Against Sexual Assault Conference 2014. Reality. Understanding society and what they think of these offenses.

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Child Sexual Abuse: Overcoming Society’s Perceptions

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  1. Child Sexual Abuse: Overcoming Society’s Perceptions Texas Association Against Sexual Assault Conference 2014

  2. 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.

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

  4. 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

  5. Your Victims?

  6. Your Victims?

  7. Your Suspect?

  8. Your Suspect?

  9. What do YOU see……

  10. What is NORMAL…..

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

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

  13. Physician Knowledge of Genital Anatomy 1 2 3 4 5 6 7 Take Home Points: Increased education, need for experienced/trained specialists doing examinations Dubow, et al. CAN 2005:195-205.

  14. Sexual Exposure

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

  16. “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 Adams. Pediatrics 1994: 310-317

  17. 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 boys • Disclosing: 7.8yrs • Non disclosing: 4.5 yrs

  18. ConclusionsHeger 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.

  19. 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) Kellogg, et al. Pediatrics 2004;113:e67-e69.

  20. How do WE overcome the perception

  21. 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.)

  22. Forensic Data in PrepubertalChildren • 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;106:100-4.

  23. 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;106:100-4.

  24. 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;106:100-4.

  25. 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;106:100-4.

  26. 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;106:100-4.

  27. Any forensic evidence vs. time # of children Hours since sexual assault Christian, et al. Pediatrics 2000;106:100-4.

  28. Forensic evidence from child’s body vs. time. # of children Hours since sexual assault Christian, et al. Pediatrics 2000;106:100-4.

  29. 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! Christian, et al. Pediatrics 2000;106:100-4.

  30. IT IS A PROCESS…..

  31. Late outcries • Why didn’t they tell • Why did they tell • Who did they tell

  32. Other obstacles….. really

  33. Children rarely tell right away.

  34. There is rarely scientific evidence.

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

  36. Children often like or even love their perpetrator.

  37. Moms will choose their boyfriends over their children.

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

  39. Justice is rarely swift.

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

  41. 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

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