Transcript Medical Forensic Response to Sexual Assault

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
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
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
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
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
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
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
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
Why Go to the ED
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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
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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
Offender Epidemiology
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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
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
Forensics
• Based on Locard’s Principle of Transference
• Includes
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History
Presentation
Injuries (medical findings)
Biological
Debris
Trace
Hair
Fibers
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
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
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
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
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
EMS Response
• Multidisciplinary approach
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Collaboration
Preservation
Observation
Documentation
• Coordinated County Protocols
– 2000 county protocols were mandated by the
Legislative body and are to be reviewed every
2 years
Collaboration
• Immediate coordinated investigation
– Law Enforcement
– CPS
– Medical Examiner
– Victim Support Services
– Emergency Department
– Specialized medical care
– Department of Health
Preservation
• Preserve Life – Render Aid
• Preserve/secure Scene
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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
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Who
When
Where
How
Observation
• Be conscious of the environment
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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
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
Medical Exception to Hearsay
• Crawford Supreme Court Decision
• Must include what you said or asked
• Verbatim in quotes what the child said
What is Your District’s Policy
• What can you do if someone signs a
waiver and you want to take the child
4 year old female ,physically and sexually abused by mom’s
new husband
Long history of meth use and manufacturing
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
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PICAA Contacts
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Barbara Haner (Medical): 425-297-5770
Medical Appointments: 425-297-5776
Consult with the NE : 425-258-9031
Gayle Ossenkop (Manager): 425-2975780
24 hour Advocacy Crisis Line
425-252-4800