Case 21
The police brought a 4-year-old girl to a child advocacy center. She had disclosed that her mother's boyfriend had touched her genital area with his fingers. The incident occurred 75 hours prior to arrival at the CAC. She denies observing ejaculation or having genital-to-genital contact. She has bathed and changed her clothes. There are no suspicious ano-genital findings.
The medical staff should:
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A. Not collect forensic evidence because the disclosure is of fondling.
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B. Consider collecting forensic evidence because DNA may still be isolated despite a lack of factors associated with evidence detection.
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C. Not collect forensic evidence because she has bathed and the incident occurred greater than 24 hours ago.
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D. A and C
The medical staff should:
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A. Not collect forensic evidence because the disclosure is of fondling.
✓
B. Consider collecting forensic evidence because DNA may still be isolated despite a lack of factors associated with evidence detection.
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C. Not collect forensic evidence because she has bathed and the incident occurred greater than 24 hours ago.
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D. A and C
The best answer is B
Factors associated with identification of evidence of sexual assault include performance of the examination within 24 hours, collection of the evidence from an unbathed child, a history of perpetrator ejaculation and/or a history of genital-genital or genital-anal contact, acute ano-genital findings and perpetrator age greater than 18 years. However, forensic evidence can be detected when these factors are not present and there may be no other indicator for abuse other than a partial or incomplete disclosure.
Because children often have normal examinations even when sexual abuse has occurred, the lack of examination findings does not preclude collection of forensic evidence. The perpetrator’s saliva or semen may be found on the child’s body, clothing or linens. Evidence may be isolated even when the child has bathed. If forensic evidence is collected, it is important to ask the police to collect the clothing that the child was wearing at the time of the incident for inclusion in the evidence for the crime laboratory and DNA testing.
Local protocols using "time" since the incident as a major factor in determining whether or not to collect forensic evidence should be flexible and allow for collection beyond 24 hours. In some cases, DNA has been isolated several days after the event occurred. In most cases, a 96-hour limit is probably sufficient.
There is often a poor correlation between a child’s description of the acts and the isolation of forensic evidence. Therefore, in this case, there may have been additional, undisclosed sexual contact and answer A is incorrect. Because recent studies have demonstrated that conducting evidence collection in the pediatric population may result in the isolation of DNA beyond 24 hours, answer C is incorrect.
For further information regarding triaging cases of suspected sexual abuse see the Additional Resources.
Further Reading
- CHAMP Practice Recommendations: Triage PDF
- Jenny C. Emergency evaluation of children when sexual assault is suspected.. Pediatrics. 2011; 128 (2) : 374-5
- Floyed RL, Hirsh DA, Greenbaum VJ, Simon HK. Development of a screening tool for pediatric sexual assault may reduce emergency-department visits.. Pediatrics. 2011; 128 (2) : 221-6
OBJECTIVE: To define the characteristics of a novel screening tool used to …
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. - Thackeray JD, Hornor G, Benzinger EA, Scribano PV. Forensic evidence collection and DNA identification in acute child sexual assault.. Pediatrics. 2011; 128 (2) : 227-32
OBJECTIVE: To describe forensic evidence findings and reevaluate previous …
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. - Girardet R, Bolton K, Lahoti S, Mowbray H, Giardino A, Isaac R, Arnold W, Mead B, Paes N. Collection of forensic evidence from pediatric victims of sexual assault.. Pediatrics. 2011; 128 (2) : 233-8
OBJECTIVE: To determine the time period after sexual assault of a child that …
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.