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.)
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
LIMITATION OF EXAMINER • Lack of Special Training • Personal biases
Child Maltreatment Medico-Legal Terminology and Interpretation of Medical Findings A CONSENSUS OF MEDICAL AND LEGAL PRACTITIONERS IN THE PHILIPPINES
Technical Working Group Members • CPU-PGH • PNP • NBI • DOH • Legal Luminaries
The Process • Review of vocabulary used internationally • Agree upon a lexicon • Agree on definition of ambiguous terms • Devise a common medical certificate
Our Goals • Improved technical understanding • Ability to “speak the same language” • Standardized procedures
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!
DEMOGRAPHIC DATA MEDICO-LEGAL CERTIFICATE 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)
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.
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
Highlights: Gives a review of basic anatomy Labia majora Hymenal orifice (vaginal opening) Shaft Hymenal membrane Urethral opening Dorsal vein Scrotum Labia minora Urethral meatus Fossa navicularis Posterior fourchette Glans Medius raphe Perineum Anus
Highlights: Gives a review of normal hymenal anatomyIllustrations of common types of hymen Annular Crescentic Cribriform
Highlights: Anal examination now standard operating procedure Perianal Skin Folds (rugal folds) Anal Verge
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)
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.”
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
Working with abused children: some useful principles • The process of investigating an allegation of abuse should not re-traumatize the child.
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
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.
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