An expert review of medical records and photographic documentation of interpreted injury to the genitals in a case of sexual abuse or assault is an critical for prosecutors and defense attorneys to assure accuracy of findings.
Sexual Abuse Expert Review – Top Ten Facts:
1. Photo or video documentation of reported injury in cases of sexual abuse or assault is standard of care. The reasons for photo or video documentation include the ability to follow injury resolution as well as afford the opportunity for a second opinion, peer review or provision as evidence in a court proceeding. An examination conducted without photo or video documentation should be reviewed for the purposes of attorney education on standard of care and quality improvement.
2. Although even the most experienced experts may disagree on whether an examination has findings of penetrating trauma, the greater the level of experience and training lends itself to greater concordance. In a study by Adams et al, Child Abuse Pediatricians had significantly increased accuracy in findings interpretation than did SANE nurses or general pediatricians.
3. Multiple techniques are essential in order to confirm a finding of a hymenal transection. In a study by Boyle et al, a review of 120 cases revealed the use of three methods/techniques was necessary in other to assess proper hymenal visualization. These techniques are: supine (lying on back) labial separation, supine labial traction and prone knee-chest position. Additional techniques of normal saline and Q-tip outline of the hymen are also quite important.
4. Standard language in sexual abuse examinations is also standard. The American Professional Society on the Abuse of Children produced a widely recognized document outlining definitions for genital and anal findings in children and teens being evaluated for sexual abuse.
5. Although Pediatric SANE nurses are an exceptionally valuable resource in medical assessments, it is critical for these examiners to engage in ongoing peer review and supervision. With great variation in training and mentorship requirements, it is wise to have findings reviewed by a child sexual abuse expert.
6. Anal findings of dilation are not diagnostic of anal injury. There are physiological reasons for the anus to dilate including normal reflexes and constipation. If you see a case whereby anal dilation is being interpreted as a finding, this is important to have reviewed.
7. The hymen has various shapes and configurations that may mimic a sexual abuse finding – especially for an examiner not familiar with hymenal morphology. A hymenal transection, which if examined with confirmatory techniques will reflect penetrating trauma, may actually be the hymen folded upon itself or a normal variant.
8. Redness (or erythema) to the genitals is not diagnostic of sexual abuse and has many causes. These include hygiene, infection and irritation – otherwise known as vaginitis. If redness or erythema to the anus or vagina is being utilized as a finding in a case of sexual abuse, it is important to have that reviewed.
9. A thorough medical history is standard of care in the evaluation of sexual abuse. Prior to interpreting findings on an exam, the examiner should be aware of any history of prior sexual abuse as well as consensual sexual experiences. Additionally, the examiner should be aware – and have reviewed – prior medical interventions (previous exams especially with use of a speculum). This is imperative so as to not attribute a finding to a specific event when in fact it may have multiple causes.
10. Most importantly, the majority of findings in sexual abuse cases are normal. A normal examination does not discount the possibility of sexual abuse. An examination done without standard techniques or documented poorly does not refute the history – meaning a child may very well have been abused even if the exam is not done properly. This is why it is imperative to have a child sexual abuse expert review findings for “both sides” (prosecution and defense) in order to assure the utmost accuracy.