Forensic medical examination of adolescent and adult victims of sexual violence

Comparison of the quality of clinical forensic examination of victims of physical violence conducted by clinicians and forensic examiners

INTRODUCTION

The Istanbul Convention calls for comprehensive care for victims of violence while maintaining forensic standards. After violent crimes, court usable documentation of injuries and securing of evidence is essential to avoid disadvantages for those affected in criminal prosecution.

MATERIAL AND METHODS

This retrospective study compares forensic relevant aspects in clinical forensic examination of victims of physical and sexual violence conducted by clinicians and forensic examiners. Forensic medical reports based on clinical documentation of individuals of all ages in the period from 2015 to 2018 (n = 132) were evaluated in comparison to a control group of examinations conducted by forensic specialists. A comparative statistical evaluation was performed.

RESULTS

The study revealed statistically significant differences in forensically relevant aspects. In the clinical examinations, full-body examination was performed in only 37.9%, and concealed body sites were examined in 9.8%. Photo documentation was often incomplete (62.4%), without scale (59.1%), blurred (39.7%), or poorly exposed (31.2%). Information on size, color, shape, and texture of injuries was often missing. In about every third examination, the findings were not described purely objective. A body scheme was used only in 8.3% of the clinical cases.

DISCUSSION

In order to establish nationwide care structures and the forensic standard required in criminal proceedings, intensive involvement of forensic medicine is essential. Standardized examination materials, regular training of medical staff, and telemedical approaches can improve the care for victims of violence regarding criminal prosecution.

The Chain of Custody in the Era of Modern Forensics: From the Classic Procedures for Gathering Evidence to the New Challenges Related to Digital Data

The purpose of this work is to renew the interest and attention for the chain of custody in forensic medicine, its establishment and maintenance, protecting the integrity and validity of evidence as well as to analyze how over time the establishment of the chain of custody and the collection of evidence has evolved also in function of the advent of technology and the use of electronic devices connected to the network. The analysis of the various aspects of the chain of custody demonstrates how necessary it is for the professional figures involved in the phases of the investigation (especially those who manage the evidence and who have, therefore, designated the assignment) to know the procedures to follow, trace the movement and the handling of objects subjected to seizure, also for the purposes of toxicological and/or histological investigations. The knowledge of interferences or complications helps to reduce errors and safeguard the validity of the evidence, assuring the proceeding judicial authority that the evidence is authentic and that it is, in other words, the same evidence seized at the scene of the crime. Furthermore, the issue is particularly felt today, with the recent need to guarantee the originality of digital data. Following a careful review and analysis of the literature currently available in this regard, it is worth adding that further efforts are needed to formulate internationally validated guidelines, harmonizing the different reference criteria in forensic science and medical areas, given the current absence of good international practices valid in the field and applicable both in the case of physical evidence and in the case of seizure of digital evidence.

Impact of Sexual Assault Survivor Identity on Patient Care in the Emergency Department

Interactions between emergency department (ED) staff and sexual assault (SA) survivors can be a source of retraumatization for survivors, increasing their risk of posttraumatic stress and decreasing utilization of longitudinal medical care. Little is known about nationwide trends in ED staff attitudes and behaviors toward survivors, including the impact of survivor identity. We conducted a survey to determine if survivor identity influenced ED staff behaviors. A nationwide survey of SA patient advocates was conducted between June and August 2021. Advocates are volunteers or staff dispatched from rape crisis centers to support survivors during ED care. Advocates participated in an online survey to determine the frequency of observing six potentially retraumatizing provider attitudes and behaviors. Adaptive questioning was used to explore the impact of survivor identity on each attitude or behavior and which identity groups were more likely to be affected. Three hundred fifteen advocates responded to the survey. Less than 10% indicated that ED staff often or always convey disbelief or blame to survivors. Almost 75% of advocates indicated that they often or always observe ED staff showing empathy to survivors. Disparities were found in provider attitudes. Over 75% of advocates observed that survivors' mental health status or substance use impacted conveyed belief from providers. Patients who were intoxicated when assaulted, had psychiatric disorders, were Black, Hispanic/LatinX, or indigenous, or were not cis-females were more likely to experience disbelief. Patients who were white and/or cis-gender females were more likely to be pressured by ED staff to complete the forensic exam and/or report to the police. Our study documents disparities in ED staff behavior towards SA survivors according to survivor identity. Given that post-assault ED interactions are critical turning points in survivors' future medical processes, disparities in ED care may be linked to larger disparities in healing from trauma.

Patient Advocates' Perspectives on the Care of Sexual Assault Survivors in Chicago-Area Emergency Departments

Emergency departments (EDs) providing care and forensic examinations for sexual assault (SA) survivors are often supported by SA patient advocates. This study explored advocates' perspectives regarding problems and potential solutions in SA patient care through a focus group with 12 advocates. Thematic analysis identified two major themes: provider-patient interactions and ED-hospital systems. Challenging aspects of provider-patient interactions included (a) provider attitudes and (b) disempowering behaviors. Within ED-hospital systems, themes included time constraints, efficiencies, and hospital preparation. Advocates surveyed were optimistic about an increased presence of SA nurse examiners and enhanced protocols and provider training to improve survivors' experiences.

Medico-legal history taking from the victims of sexual assaults: the role of nurse examiners

Background

Sexual assault examiners provides comprehensive health care to victims of sexual assault. Communication with the victim is important to collect relevant information from the victims. Ineffective communications can cause re-victimization and hamper the medico-legal evidence collection.

Main text

This article aims to orient the novice examiner and nurses to the prerequisites of medico-legal history collection, techniques of building trust, establishing rapport, ensuring privacy and confidentiality, taking consent, communicating effectively with the victims of sexual assault, and components of medico-legal history collection.

Conclusions

Novice examiners and nurses need to be trained in collecting medico-legal history and evidence. The examiners who conduct the examination should be dedicated to delivering compassionate and high-quality care to individuals who have disclosed sexual assault.

Geographies of Sexual Assault: A Spatial Analyses to Identify Neighborhoods Affected by Sexual and Gender-Based Violence

Emergency departments are a common access point for survivors of sexual and gender-based violence (SGBV), but very little is known about where survivors live and the neighborhoods they return to. The objectives of this study were to describe the patient population that present for a sexual or partner-based assault and explore the geographic distribution of cases across the Ottawa-Gatineau area. Data for this study were extracted from the Sexual Assault and Partner Abuse Care Program (SAPACP) case registry (January 1 to December 31, 2015) at The Ottawa Hospital. Spatial analyses were conducted using six-digit postal codes converted into Canadian Census Tract units to identify geographic areas with concentrated cases of SGBV. Concentrated areas were defined as Census Tracts with seven or more SGBV cases within a single calendar year. In 2015, there were 406 patients seen at the SAPACP and 348 had valid postal codes and were included in the analyses. More than 90% of patients were female and 152 (43.68%) were below 24 years of age. More than 70% knew their assailant and the most common locations of the assault were at the survivors' home (31.03%), assailants' home (27.01%), or outdoors (10.92%). Eight concentrated areas were identified including three in the downtown entertainment district, three lower income areas, one high-income neighborhood, and one suburb more than 20 km from downtown. The findings from this study describe the typical clinical presentation of sexual and domestic assault survivors and also challenge geographic stereotypes of where survivors live and what areas of the city are most affected by SGBV. Using residential information provides a survivor-centric approach that highlights the widespread nature of SGBV and supports the need for population-based approaches to improve care for survivors.

Collection and storage of forensic evidence to enable subsequent reporting of a sexual crime to the police "Option 3"-an Irish experience

BACKGROUND

Sexual Assault Treatment Units (SATUs) provide holistic care, frequently including forensic examination, for people who disclose sexual violence. Storage of forensic evidence without reporting to An Garda Síochána (AGS), the Irish national police service (Option 3), was introduced in August 2016. This allowed attendees time to decide whether they wanted to report to AGS, without the loss of all forensic evidence.

AIMS

This paper presents a retrospective analysis of all "Option 3" cases including their subsequent disclosures to AGS, at the Dublin SATU, between 1 Aug. 2016 and 30 Jul 2020.

METHODS

The contemporaneous medical charts of Option 3 cases were reviewed and anonymised data extracted from them.

RESULTS

During the study period, there were 1258 attendances to the Dublin SATU. Of these, 10% (n = 127/1258) were Option 3. Ninety-three percent (n = 118/127) were female and 7% (n = 9/127) were male. The mean age was 26. Seventy percent (89/127) indicated a sexual assault occurred and 30% (38/127) were unsure. Twenty percent (n = 25/127) subsequently reported the incident to AGS, 60% (n = 15/25) within 7 days, and 80% (n = 20/25) within 1 month. Eighty percent (n = 20/25) of these reported cases had their evidence retrieved by AGS for analysis. Three percent (n = 4/127) requested that their evidence kits be kept for an additional year. None of these patients reported over that following year, and their evidence was subsequently destroyed.

CONCLUSION

In conclusion, the availability of Option 3 has afforded people the opportunity to access responsive SATU care including storage of forensic evidence which may have significant evidential value. This potentially provides further opportunities for comprehensive detection of a crime, even if reporting to AGS is delayed.

Forensic photo-documentation in adult sexual assault- what do patients think?

Historically, some forensic practitioners and policy makers have viewed the use of photography in forensic documentation for adult victims of sexual assault as controversial. Some argue that diagrams and verbal descriptions of injury are sufficient, suggesting that sexual assault victims are so traumatised at time of examination that they are not able to provide valid consent, that the imaging process itself is humiliating, and that any decision to have photographs taken might be later regretted. Objectively, a patient capable of consenting to a forensic examination has an equal capacity to consent for forensic imaging, even when this involves sensitive areas of the body, and the process of forensic photography is not inherently problematic. Literature on forensic photography is sparse, particularly from the patient perspective. Our Forensic Medical Unit is in an excellent position to investigate this issue, as it is one of the few services in Australia that routinely offers sexual assault forensic photography, including genital, as part of its standard procedures for injury documentation. Photographs, in adult sexual assault cases, are not routinely taken of normal anatomy nor are they ever taken without patient consent. This study explores the immediate and short-term experiential impacts of forensic photography from the victims' perspective. Capacity to consent was assessed using a trauma informed, evidence-based interviewing tool at the start of their forensic assessment. Participants also completed questionnaires at the conclusion of their examination and on follow-up. Results show that victims not only have the capacity to provide informed consent but also found forensic photography, and the reasons for it, quite acceptable. A majority [80%; n = 87/108] indicated the photographic process had either been not at all or only a little embarrassing. When asked how they felt about having photographs taken, the majority 93.4% [n = 99/106) indicated that as well as having no regrets they were also happy with the way the images had been taken. 4.7% [n = 5] expressed some doubt about whether they had made the right decision. A similar pattern of responses was observed at follow-up which occurred, on average, seven weeks post examination. 72% [n = 26/36] said they did not think about the photographs at all or did so rarely. While 14% [n = 5/36] said they thought about them a fair bit or a lot of the time, most stated they had no concerns regarding the images that had been taken. Given its evidentiary salience and other benefits, such as its potential to promote greater transparency in the provision of forensic opinions and its usefulness in teaching, this study supports the case for the routine use of forensic photography in adult Sexual Assault Units more broadly.

Emergency Department Management of the Sexual Assault Victim in the COVID Era: A Model SAFET-I Guideline From San Diego County

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has contributed to an increase in intimate partner violence (IPV), posing challenges to health care providers who must protect themselves and others during sexual assault examinations. Victims of sexual assault encountered in prehospital and emergency department (ED) settings have legal as well as medical needs. A series of procedures must be carefully followed to facilitate forensic evidence collection and law enforcement investigation. A literature review detected a paucity of published guidance on the management of sexual assault patients in the ED, and no information specific to COVID-19.

OBJECTIVE

Investigators sought to update the San Diego County sexual assault guidelines, created in collaboration with health care professionals, forensic specialists, and law enforcement, through a consensus iterative review process. An additional objective was to create a SAFET-I Tool for use by frontline providers during the COVID-19 pandemic.

DISCUSSION

The authors present a novel SAFET-I Tool that outlines the following five components of effective sexual assault patient care: stabilization, alert system activation, forensic evidence consideration, expedited post-assault treatment, and trauma-informed care. This framework can be used as an educational tool and template for agencies interested in developing or adapting existing sexual assault policies.

CONCLUSIONS

There is a lack of clinical guidance for ED providers that integrates the many aspects of sexual assault patient care, particularly during the COVID-19 pandemic. A SAFET-I Tool is presented to assist emergency health care providers in the treatment and advocacy of sexual assault patients during a period with increasing rates of IPV.

Clinical forensic medicine in Eastern Denmark: Organisation and assessments

Internationally, clinical forensic medicine (CFM) is diverse in content and conduct, and forensic medical methods are not always evidence based. The first step towards evidence-based practice is to achieve a thorough knowledge of international diversity, which necessitates that CFM practitioners provide information about their national practice. This paper’s aim is to describe the organisation of CFM in Denmark, exemplified by the set-up in Eastern Denmark, and the types of assessments performed. In Denmark, forensic medicine is a board-certified specialty under the health authorities, with mandatory qualifications. The Danish Accreditation Fund accredits the Departments of Forensic Medicine as inspection bodies, according to an international European standard that is approved by Danish Standards. Mainly at police request, forensic doctors perform examinations of both victims and suspected perpetrators of perilous crimes. The examinations’ purposes are documentation and assessment of the findings and collection of biological evidence. The clinical forensic examinations do not include any treatment or medical follow-up. Thus, the forensic doctors must be neutral, objective and impartial. The clinical forensic examinations provide documentation of findings and conclusions not otherwise available for the police investigation and legal aftermath. Moreover, the accredited, standardised protocols ensure that the Departments of Forensic Medicine meet their obligations as inspection bodies, thus ensuring public confidence in the departments’ services.

Current care for victims of sexual violence and future sexual assault care centres in Belgium: the perspective of victims

Background

Sexual violence is a global health problem. After ratifying the Convention of Istanbul in 2016, this Belgian study was set up to map the perspective of victims of rape on the current sexual violence care provision in Belgium and to inquire on their need for more specialised and holistic care in future Sexual Assault Care Centres.

Methods

Sixteen rape victims participated in this sub-study. A mixed-method design (questionnaire, in-depth interview or small focus group) was applied depending on the time elapsed between rape and participation. Descriptive Thematic Framework Analysis was performed in duo.

Results

The participants thought it of utmost importance that every victim should receive all medical, psychological and forensic care without necessarily having to involve the police first. They stated that the current Belgian sexual violence care provision could be much more patient-centred, specifically the forensic examination and psychological care. Alongside medical and psychological consequences, victims emphasised the high personal financial and relational burden of sexual violence.

The holistic care offered in Sexual Assault Care Centres was perceived to enhance the recovery process of victims of sexual violence. Their doors should be open to all victims and their relatives. They should not only provide acute care for the victim, but also improve victims’ reintegration into society while reducing their personal costs significantly.

Conclusion

All care for victims of sexual violence, especially forensic and psychological care, needs drastic improvement in Belgium. All participants agreed that having specialised, multidisciplinary and longitudinal care in a Sexual Assault Care Centre that would be open 24/7 for everyone, victims and their significant others, would be an improvement to the currently available care all over Belgium.

Trial registration

This research was registered on April 1st 2016. Registration number B670201628242.

The significance of the forensic clinical examination on the judicial assessment of rape complaints - developments and trends

OBJECTIVE

The aim of this study was to investigate the role of the forensic clinical examination in the judicial assessment made by the Prosecution Service in cases of rape.

METHODS

All cases of police-reported sexual assault in the county of Funen, Denmark in a six-year period were reviewed, and the retrospective data was collected. Cases in which a forensic clinical examination was performed were included.

RESULTS

The Prosecution Service in the county of Funen received 348 police-reported rape cases and of these 184 cases were included. The Prosecution Service stated that the forensic clinical examination (FCE) was important for the decision-making process in approximately half of the cases. The Prosecution Service finding an FCE important due to the presence of relevant findings was significantly associated with the case going to trial, whereas importance due to absence of relevant findings was significantly associated with the cases not going to trial. The only single factor associated with a case going to court and a guilty verdict was an FCE of the alleged perpetrator. There were no crude associations between any other factors i.e. the type of assault, victim injuries or alcohol consumption. In a logistic regression model, however, it was significantly more likely (p < 0.05) that a forensic clinical examination of the victim was used in the Prosecution Service's decision if there were both anogenital and extra-genital injuries documented, that could originate from the alleged crime. The odds were 7.83 times higher compared to if no injuries were detected. The Prosecution Service's use of the clinical examination in their argumentation of the decision of a rape complaint has been significantly increasing from 2003 to 2015.

CONCLUSION

The results of the first in-depth analysis of the overall importance of a forensic clinical examination in cases of rape and sexual assault shows that we need to continuously focus on the documentation of sexual assault, as documentation is part of the decision-making process at all stages of the judicial process.

Genitoanal Injury in Sexually Assaulted Adult Women: Six-Year Retrospective in Bangkok

Sexual assault persists as a global problem. Even when sexual assault does not result in obvious visible wounds, genitoanal injury must be evaluated because it is often pertinent for legal outcomes. Macroscopic ("naked eye") examination is valuable when colposcope is not available or when patients do not consent. This study reviewed the genitoanal injuries of 117 sexually assaulted adult women evaluated macroscopically. Genitoanal injury prevalence was 47%, and nongenitoanal injury prevalence was at 44%. The most common injury type was abrasion, and the most common site was posterior fourchette. Most injury patterns were singular. The number of women who did not report a history of sexual intercourse in the sample and usage of fingers/palm during assault may have affected pattern and/or injury type. There was a significant relationship between hymenal old tear below the 3- to 9-o'clock area and prior sexual intercourse. Factors related to genitoanal injury were prior sexual intercourse, vaginal delivery, and spermatozoa detection. In conclusion, all sexually assaulted women should be encouraged to have a pelvic examination: nothing overtly visible does not mean that nothing happened.

Establishing Sexual Assault Care Centres in Belgium: health professionals' role in the patient-centred care for victims of sexual violence

BACKGROUND

Having ratified the Convention of Istanbul, the Belgian federal government commits itself to the foundation of Sexual Assault Care Centres (SACC). In the light of researching the feasibility of these centres, this study aimed to evaluate the care for victims of sexual violence (SV) in Belgian hospitals anno 2016 as well as to formulate recommendations for the intended model.

METHODS

Between April and October 2016, a questionnaire was distributed to 159 key health professionals active in 17 different hospitals attached to an AIDS Referral Centre. The survey covered four parts, i.e. the health professionals' profile, their knowledge, attitude and practices, an assessment of the hospital's policy and the caregivers' opinion on the care for victims of SV and on the intended SACCs. Subsequently, a descriptive analysis using 'IBM SPSS Statistics 23' was performed.

RESULTS

A total of 60 key health professionals representing 15 different hospitals completed the questionnaire resulting in a response rate of 38%. The results showed a lack of knowledge and practical experience of caregivers' regarding the care for SV victims. Approximately 30% of responders face personal or professional difficulties upon provision of care to victims of SV. Participants evaluate the current care as good, despite the limited psychosocial support, follow-up, insight for the needs of vulnerable groups and support for family, relatives and health professionals. Yet, the majority of health professionals appraise the SACCs as the best approach for both victims and caregivers.

CONCLUSIONS

By introducing a SACC, the Belgian federal government aims to provide holistic and patient-centred care for victims of SV. Essential in patient-centred health care is an extensive and continuous education, training and supervision of health professionals concerning the care for victims, support for family, relatives and caregivers. At the end and as a result of a participatory process with many professional experts as well as victims, a specific Belgian model, adjusted to the health care system anno 2016 was developed for piloting. The main challenges in establishing SACCs are situated at the institutional and policy level. Collaborating with other institutions and further research are herewith required.

Towards a more integrated and gender-sensitive care delivery for victims of sexual assault: key findings and recommendations from the Belgian sexual assault care centre feasibility study

BACKGROUND

Sexual assault remains a major threat to public health, affecting every gender, gender identity and sexual orientation. Following the Belgian ratification of the Istanbul Convention in 2016, the feasibility of a Belgian sexual assault centre model was investigated, aiming to provide more integrated and patient-centred health and judiciary services to victims of sexual assault. By actively involving health professionals, police and judiciary system representatives, as well as victims themselves, this feasibility study eventually fed into the Belgian Sexual Assault Care Centre model. In this process, this paper assessed current Belgian health services and the degree to which the implementation of this model could contribute to both a more integrated and gender-sensitive care delivery. Findings from this study and the subsequent recommendations aim to contribute to similar reforms in other countries that have already taken or are about to take steps towards an integrated, multi-agency support framework for victims of sexual assault.

METHODS

A qualitative, descriptive analysis of the survey response of 60 key health professionals (N = 60) representing 15 major Belgian hospitals was first conducted. Comparing their approach with the international guidelines and standards, a Strengths Weaknesses Opportunities and Threats analysis of the current sexual assault health services and their potential transition to the Sexual Assault Care Centre model was then executed.

RESULTS

Despite adequate equipment, the clear fragmentation of health services and limited follow-up hamper an integrated care delivery in most hospitals. Only three hospitals differentiated their sexual assault care protocol based on the victim's gender, gender identity and sexual orientation. A striking unawareness among health professionals of sexual assault in male victims, as well as in gender and sexual minorities further hampers a gender-sensitive care delivery.

CONCLUSIONS

The Sexual Assault Care Centre model aims to counter most of the current sexual assault health services' weaknesses and threats hampering an integrated care for victims of sexual assault. Further research and training of health professionals are however required in order to tune this integrated form of care to sexuality and gender-based differences in victims' already multi-faceted healthcare needs.

Effects of microbial DNA on human DNA profiles generated using the PowerPlex® 16 HS system

Most crime scenes are not sterile and therefore may be contaminated with environmental DNA, especially if a decomposing body is found. Collecting biological evidence from this individual will yield DNA samples mixed with microbial DNA. This also becomes important if postmortem swabs are collected from sexually assaulted victims. Although genotyping kits undergo validation tests, including bacterial screens, they do not account for the diverse microbial load during decomposition. We investigated the effect of spiking human DNA samples with known concentrations of DNA from 17 microbe species associated with decomposition on DNA profiles produced using the Promega PowerPlex^® HS system. Two species, Bacillus subtilis and Mycobacterium smegmatis, produced an extraneous allele at the TPOX locus. When repeated with the PowerPlex^® Fusion kit, the extra allele no longer amplified with these two species. This experiment demonstrates that caution should be exhibited if microbial load is high and the PowerPlex^® 16HS system is used.

Acute Sexual Assault in the Pediatric and Adolescent Population

Children and adolescents are at high risk for sexual assault. Early medical and mental health evaluation by professionals with advanced training in sexual victimization is imperative to assure appropriate assessment, forensic evidence collection, and follow-up. Moreover, continued research and outreach programs are needed for the development of preventative strategies that focus on this vulnerable population. In this review we highlight key concepts for assessment and include a discussion of risk factors, disclosure, sequelae, follow-up, and prevention.