Pediatric sexual assault nurse examiner care: trace forensic evidence, ano-genital injury, and judicial outcomes

Interpretation of medical findings in suspected child sexual abuse: An update for 2023

Health care professionals who examine children who may have been sexually abused need to be able to recognize, and photo-document any physical signs, and to have access to expert reviewers, particularly when signs concerning for sexual abuse are found. Although the general consensus among practitioners is that children will show few signs of sexual abuse on examination, there is considerable variability and rates of positive exam findings among practitioners of different professions, practice settings, and countries. This review will summarize new data and recommendations regarding the interpretation of medical findings and sexually transmitted infections (STIs); assessment and management of pediatric patients presenting with suspected sexual abuse or assault; and testing and treating patients for STIs. Updates to a table listing an approach to the interpretation of medical findings are presented, and reasons for changes are discussed.

Emergency Care Utilization for Mental and Sexual Health Concerns Among Adolescents Following Sexual Assault: A Retrospective Cohort Study

PURPOSE

This study aimed to explore the health outcomes of adolescent survivors of sexual assault, as measured by subsequent emergency department (ED) utilization for mental and sexual health concerns.

METHODS

This retrospective cohort study used the Pediatric Health Information System (PHIS) database. We included patients aged 11-18 years seen at a PHIS hospital with a primary diagnosis of sexual assault. The control group included age- and sex-matched patients seen for an injury. Participants were followed in PHIS for 3-10 years; subsequent ED visits for suicidality, sexually transmitted infection, pelvic inflammatory disease (PID), or pregnancy were identified, and likelihoods of each were compared using Cox proportional hazards models.

RESULTS

The study population included 19,706 patients. ED return visit rates in the sexual assault and control groups were 7.9% versus 4.1% for suicidality, 1.8% versus 1.4% for sexually transmitted infection, 2.2% versus 0.8% for PID, and 1.7% versus 1.0% for pregnancy, respectively. Compared to controls, sexual assault patients were significantly more likely to return to the ED for suicidality throughout the follow-up period, with the highest hazard ratio of 6.31 (95% confidence interval 4.46-8.94) during the first 4 months. Sexual assault patients also had higher likelihood of returning for PID (hazard ratio 3.80, 95% confidence interval 3.07-4.71) throughout the follow-up period.

DISCUSSION

Adolescents seen in the ED for sexual assault were significantly more likely to return to the ED for suicidality and sexual health concerns, highlighting the need for increased allocation of research and clinical resources to improve their care.

Preservation of forensic traces by Nursing in emergency services: a scoping review

OBJECTIVE

to map the scientific production on the preservation of forensic traces by Nursing professionals working in emergency services.

METHOD

a scoping review, with searches for studies carried out in six databases, in the gray literature available in Google Scholar and in the references of the studies selected. For analysis, the data reduction method was adopted.

RESULTS

26 studies were included, organized into five categories: 1) Nursing professionals' knowledge on the preservation of forensic traces; 2) Procedures performed by Nursing to preserve traces in the victim's body; 3) Procedures performed by Nursing to preserve traces in the victim's belongings/objects; 4) Procedures performed by Nursing to document traces; and 5) Actions to maintain the chain of custody performed by Nursing.

CONCLUSION

the studies showed situations in which the emergency nurse may act in the preservation of forensic traces present in the victim's body and in objects, as well as in the registration of traces, verifying the role of Nursing to ensure integrity of the chain of custody, especially in situations of aggression, firearm injury, sexual violence, child abuse and assistance to trauma victims.

Multidisciplinary Approach to Emergent Sexual Abuse in a Pediatric Emergency Department: A Simulated Child Advocacy Center Model of Care

INTRODUCTION

The purpose of this study was to compare child sexual abuse interview disclosures and judicial outcomes for cases of child and adolescent sexual abuse/assault seen in a pediatric emergency department (PED) before and after the implementation of a simulated child advocacy center (CAC) multidisciplinary model of care.

METHOD

A retrospective chart and legal records review was conducted from both the PED model of care group and the simulated CAC multidisciplinary model of care for judicial outcomes, child sexual abuse interview disclosures, and sexual abuse case characteristics.

RESULTS

The simulated CAC multidisciplinary model of care did not result in increased indictments, pleas, trials, or disclosure of sexual abuse in the sexual abuse interview when compared with the PED model of care. The simulated CAC multidisciplinary model of care did result in a significantly higher rate of sexual abuse interview completion.

DISCUSSION

Demographic risk factors for sexual abuse victimization as well as perpetration have been identified in the literature and were supported by this study. Law enforcement and child protective services were more frequently present in the PED under the simulated CAC multidisciplinary model allowing for improved protection of children.

Indiana Sexual Assault Nurse Examiner Training Initiative: Positive Impacts for Medical Forensic Care

BACKGROUND

Indiana ranks among the highest in the nation for child abuse and neglect reports. Already facing a persistent shortage of sexual assault nurse examiners (SANEs) to serve patients across the life span, residents with medical forensic needs were often being referred to other hospitals across the state for care or simply were not receiving medical forensic examinations because of lack of access to trained examiners. The Indiana SANE Training Project was established to evaluate the forensic nursing workforce throughout Indiana and work to expand access to qualified SANEs through training and collaboration with stakeholders, with a focus on rural and underserved areas of the state.

METHODS

The Project gathered information from nurses who participated in activities during the first Project year. This information was evaluated for service gaps and ongoing training needs. The project coordinator then convened a workgroup of stakeholders and subject matter experts to evaluate and respond to the most immediate need-limited access to pediatric medical forensic providers.

RESULTS

From September 2018 to December 2019, nurses were trained by the Project ( n = 160). Of those, 86% indicated that their hospital did not provide medical forensic examinations to pediatric patients. The Pediatric SANE Intensive was launched in October 2020 and trained pediatric SANEs ( n = 28). Upon completion, participants reported 47% increase in confidence and 56% increase in competence related to caring for pediatric patients.

DISCUSSION

Statewide collaboration is a critical component of establishing a consistent approach to care, strengthening multidisciplinary partnerships, increasing access to medical forensic services across the life span and in rural and underserved areas, and promoting the Indiana Guidelines for Medical Forensic Examination of Pediatric Sexual Abuse Patients.

Health care providers' responses to sexually abused children and adolescents: a systematic review

Background

Sexual abuse of children and adolescents is a significant health concern worldwide. Appropriate and timely health services for victims can prevent severe and long-term consequences. This study identified and categorized diagnostic and treatment services needed for sexually abused children and adolescents.

Methods

Several databases, including MEDLINE, Web of Science, Scopus, Science Direct, ProQuest, and Google Scholar, were searched to retrieve studies on the topic and clinical guidelines in English covering the literature from 2010 to 2020 using search terms. Primary studies and guidelines were reviewed to identify treatment strategies and medical interventions related to sexually abused children and adolescents.

Results

Twenty-one studies and guidelines were selected and analyzed narratively. The quality of evidence was relatively good. We identified that effective health care systems for sexually abused children include the following: interview and obtain medical history, physical and anogenital examination, collecting forensic and DNA evidence, documenting all the findings, prevention and termination of pregnancy, diagnostic tests, prophylaxis for HIV and other STIs, vaccinations, and psychological intervention.

Conclusions

This review provides up-to-date evidence about adequate health care services for children and adolescent victims of sexual abuse. We conclude that recent studies have focused more on prophylaxis against HIV and other STIs, studies on vaccinating against HPV for victims are still limited, and future research in this area is needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07814-9.

Preservación de los rastros forenses que realizan los enfermeros en los servicios de emergencias: revisión de alcance

Resumen Objetivo: mapear la producción científica sobre la preservación de rastros forenses por profesionales de enfermería que trabajan en los servicios de emergencias. Método: revisión de alcance, con búsqueda de los estudios realizados en seis bases de datos, en la literatura gris disponible en Google Scholar y en las referencias de los estudios seleccionados. Para el análisis, se adoptó el método de reducción de datos. Resultados: se incluyeron 26 estudios organizados en cinco categorías: 1) Conocimiento de los profesionales de enfermería sobre la preservación de rastros forenses; 2) Procedimientos que realizan los enfermeros para preservar rastros en el cuerpo de la víctima; 3) Procedimientos que realizan los enfermeros para preservar rastros en las pertenencias/objetos de la víctima; 4) Procedimientos que realiza el personal de enfermería para documentar los rastros; y 5) Acciones que llevan a cabo los enfermeros para mantener la cadena de custodia. Conclusión: los estudios demostraron que hay situaciones en las cuales el enfermero de emergencias puede actuar para preservar los rastros forenses presentes en el cuerpo de la víctima y en los objetos, así como también registrar los rastros, lo que comprueba la actuación del enfermero para garantizar la integridad de la cadena de custodia, particularmente en situaciones de agresión, heridas con arma de fuego, violencia sexual, abuso infantil y asistencia a víctimas de trauma.

Preservation of forensic traces by Nursing in emergency services: a scoping review

Objective:

to map the scientific production on the preservation of forensic traces by Nursing professionals working in emergency services.

Method:

a scoping review, with searches for studies carried out in six databases, in the gray literature available in Google Scholar and in the references of the studies selected. For analysis, the data reduction method was adopted.

Results:

26 studies were included, organized into five categories: 1) Nursing professionals’ knowledge on the preservation of forensic traces; 2) Procedures performed by Nursing to preserve traces in the victim’s body; 3) Procedures performed by Nursing to preserve traces in the victim’s belongings/objects; 4) Procedures performed by Nursing to document traces; and 5) Actions to maintain the chain of custody performed by Nursing.

Conclusion:

the studies showed situations in which the emergency nurse may act in the preservation of forensic traces present in the victim’s body and in objects, as well as in the registration of traces, verifying the role of Nursing to ensure integrity of the chain of custody, especially in situations of aggression, firearm injury, sexual violence, child abuse and assistance to trauma victims.

Comparative Study of Acute Anogenital Injury Between Consensual and Nonconsensual Postmenarche Adolescents

ABSTRACT

In Thailand, sexual activity involving those under the legal age of consent may be legally and medically problematic, even if it is consensual. Thus, differentiating anogenital injury characteristics that occur during consensual versus nonconsensual acts with adolescent female subjects could aid legal advocates and improve health care and social support for these patients. Our study included postmenarche female patients having acute anogenital injuries after consensual and nonconsensual penetration. We found that nonconsenting patients had more cases of anogenital injury than consenting (69.8% vs 55.5%), with at least 1 abrasion, contusion, laceration, labia major or minor injury, and external or internal site injury. Both consensual and nonconsensual cases had the same common sites for injury type, reflecting the same injury mechanism; prior sexual intercourse was a significant protective factor against some anogenital injury prevalence, types, and sites for both groups. Adolescents forced into nonconsensual acts had more nonanogenital injuries. Looking at factors such as age, prior sexual activity history, and use of condom and/or contraceptive pills, it is very clear that early sexual education, particularly around consent, is critically needed in Thailand for the best interests of adolescents and children so that they and/or their guardians can access the health and legal resources required.

A trauma-informed guide to caring for adolescents following sexual assault

PURPOSE OF REVIEW

Sexual assault is common among adolescents worldwide. Survivors of sexual assault may experience various immediate and long-term effects on their physical and mental health. It is important that pediatric healthcare providers (HCPs) are aware of the high prevalence of sexual assault and recognize the impact on their adolescent patients. The aim of this update is to discuss how pediatric HCPs can embody a trauma-informed approach when caring for survivors of sexual assault across various settings.

RECENT FINDINGS

All adolescent patients should be screened for sexual assault during routine clinical visits; in responding to a disclosure, providers should exhibit compassion, express validation, and help connect the patient to resources to aid in healing. Caring for survivors of sexual assault should ideally be multidisciplinary, involving treatment of the medical complications (including the possibility of pregnancy or infection) and mental health sequelae (including increased likelihood of depression, posttraumatic symptoms, and suicidality).

SUMMARY

A trauma-informed approach can be applied to all aspects of caring for survivors of sexual assault, from screening for sexual assault and responding to disclosure, to providing acute and longitudinal care following sexual assault.

Sexual Assault in an Adolescent Female: A Pediatric Simulation Case for Emergency Medicine Providers

INTRODUCTION

Many emergency medicine (EM) physicians have limited training in the care of sexual assault patients. Simulation is an effective means to increase the confidence and knowledge of physicians in such high-stakes, low-frequency clinical scenarios as sexual assault. We sought to develop and implement a sexual assault simulation with a structured debriefing for EM residents and to determine its impact on resident learners' attitudes and knowledge skills in the care of patients with sexual assault.

METHODS

The simulation blended psychomotor skills (e.g., collecting forensic evidence), cognitive skills (e.g., ordering laboratory studies and medications), and communication skills (e.g., obtaining relevant patient history, responding to psychosocial concerns raised by team members and simulator). Our emergency department checklist was available as a cognitive aid for each step of the evidence collection process. A content expert answered questions in real time during the simulation and provided structured debriefing following the simulation. Trainees completed an anonymous survey within a week after the intervention and a follow-up survey within 8 months.

RESULTS

Nineteen EM trainees participated. Presimulation, 39% reported never having received training in the medical care of a patient with sexual assault. The proportion of trainees agreeing or strongly agreeing with the statement "I am comfortable and confident managing a case of sexual assault" increased from 21% to 74% following the simulation (p < .05).

DISCUSSION

This intervention was associated with EM trainees' increased confidence with and knowledge of medical and forensic evaluations for an adolescent with sexual assault.

Implementation of the Dutch expertise centre for child abuse: descriptive data from the first 4 years

OBJECTIVE

Combined paediatric and forensic medical expertise to interpret physical findings is not available in Dutch healthcare facilities. The Dutch Expertise Centre for Child Abuse (DECCA) was founded in the conviction that this combination is essential in assessing potential physical child abuse. DECCA is a collaboration between the three paediatric hospitals and the Netherlands Forensic Institute. DECCA works with Bayes' theorem and uses likelihood ratios in their conclusions.

DESIGN

We present the implementation process of DECCA and cross-sectional data of the first 4 years.

PARTICIPANTS

Between 14 December 2014 and 31 December 2018, a total of 761 advisory requests were referred, all of which were included in this study. An advisee evaluation over the year 2015 was performed using a self-constructed survey to gain insight in the first experiences with DECCA.

RESULTS

761 cases were included, 381 (50.1%) boys and 361 (47.4%) girls (19 cases (2.5%) sex undisclosed). Median age was 1.5 years (range 1 day to 20 years). Paediatricians (53.1%) and child safeguarding doctors (21.9%) most frequently contacted DECCA. The two most common reasons for referral were presence of injury/skin lesions (n=592) and clinical history inconsistent with findings (n=145). The most common injuries were bruises (264) and non-skull fractures (166). Outcome of DECCA evaluation was almost certainly no or improbable child abuse in 35.7%; child abuse likely or almost certain in 24.3%, and unclear in 12%. The advisee evaluations (response rate 50%) showed that 93% experienced added value and that 100% were (very) satisfied with the advice.

CONCLUSION

Data show growing interest in the expertise of DECCA through the years. DECCA seems to be a valuable addition to Dutch child protection, since advisee value the service and outcome of DECCA evaluations. In almost half of the cases, DECCA concluded that child abuse could not be substantiated.

Position Statement: Child Maltreatment: International Association of Forensic Nurses Board of Directors, 2019

The International Association of Forensic Nurses has developed a Position Statement regarding child maltreatment. The Position Statement identifies the problem statement, association position, and rationale for interventions.

How Do Nurses Keep Children Safe From Abuse and Neglect, and Does it Make a Difference? A Scoping Review

OBJECTIVES

To explore the extent of child protection work performed by nurses and identify which interventions hold the strongest evidence for future practice.

DESIGN

This scoping review was guided by Arksey and O'Malley's framework for scoping reviews.

DATA SOURCES

Electronic databases (CINAHL, Medline, Scopus, Web of Science) and grey literature were searched in August 2017. Further studies were identified through manual literature searching.

RESULTS

Forty-one studies from seven countries met the inclusion criteria. The studies showed nurses keep children safe primarily through the prevention of abuse (n = 32), but also through detection of abuse (n = 1) and interventions to mitigate the effects of abuse (n = 8). Nurses' specific interventions most frequently involved post-natal home visiting (n = 20), parent education (n = 10) and assessment and care of children or adolescents following sexual abuse (n = 4). The main findings showed that although nurses did have positive impacts upon some measures of abuse and neglect, results were not consistent across studies. In addition, some studies used indirect measures of abuse and neglect, which may not impact children's experiences of abuse. It is difficult to extrapolate these findings to the broader nursing profession as literature did not accurately represent the range of ways that nurses keep children safe from abuse and neglect.

CONCLUSIONS

This review demonstrated nurses prevent, detect and respond to abuse and neglect in many ways. However, given mixed evidence and absence of some nurse interventions in the literature, further research is needed to represent the range of ways that nurses keep children safe and determine their effectiveness.

Qualitative Analysis of Prosecutors' Perspectives on Sexual Assault Nurse Examiners and the Criminal Justice Response to Sexual Assault

OBJECTIVE

The aim of this study was to understand prosecutors' perspectives on the contribution of Sexual Assault Nurse Examiners (SANEs) to evidence collection and trials in sexual assault cases.

BACKGROUND

Several studies have suggested that a sexual assault case is more likely to progress in the criminal justice system when a SANE conducts the forensic medical examination. However, little is known about how prosecutors perceive SANEs and what they value about SANEs versus other medical professionals.

METHOD

Semistructured interviews, conducted in one jurisdiction with eight assistant district attorneys who prosecute sexual assault cases, included questions about the value of SANEs in evidence collection and trials. Interview transcripts were analyzed to identify common themes and variability among prosecutors.

RESULTS

Most prosecutors identified advantages for SANEs in evidence collection, trial preparation, and testimony. Specific advantages cited by one or more prosecutors included superior documentation, thoroughness of the physical examination, better identification of injuries, quality of relationships with patients, professionalism, skill in trial preparation and testifying, and credibility with jurors.

DISCUSSION

These findings help validate SANEs' contribution to the criminal justice response to sexual assault, despite the study's limitations in sample size and inclusion of only one jurisdiction. The study also suggests the value of further education about SANEs for prosecutors who may not have the opportunity to learn about the range of skills SANEs possess.

Is there a role for paediatric Sexual Assault Nurse Examiners in the management of child sexual assault in Australia?

In Australia, paediatricians and Child Protection Specialists provide the medical and forensic examinations of child victims of sexual assault. There are workforce challenges in the recruitment and retention of doctors to undertake child sexual assault (CSA) work particularly in remote and rural areas. Pediatric Sexual Assault Nurse Examiner (PSANE) programs have existed in the USA and the UK for many years. Using Rapid Evidence Assessment (REA) methodology, a systematic search of the literature was performed to ascertain what is known about SANE programs, to evaluate the evidence for their effectiveness across a number of domains (accessibility, health and legal outcomes and cost effectiveness) and to inform policy on models of care and elements of best practice which may be appropriate for local implementation in Australia. This review showed that despite the limited evidence available and significant gaps in the evidence, SANEs provide a high standard of medical care and are not detrimental to the legal process. By providing recommendations regarding the potential value, effectiveness and feasibility of establishing a PSANE program in Australia, this article may be of interest to other high income countries facing similar workforce challenges in meeting the needs of children with alleged sexual assault.

Improving the Credibility of Child Sexual Assault Victims in Court: The Impact of a Sexual Assault Nurse Examiner

The present study investigated the influence of a sexual assault nurse examiner's (SANE's) testimony on mock juror perceptions of a child or adolescent victim of child sexual assault. Community members (N = 252, 156 females) read a fictional criminal trial summary of a child sexual assault case in which the victim was 6 or 15 years old and the prosecution presented medical testimony from a SANE or a traditional registered nurse (RN), or did not present medical testimony. Mock jurors were more likely to render guilty verdicts when a SANE testified compared with the other two testimony conditions. In addition, pro-victim judgments (e.g., sympathy toward the victim) and negative defendant judgments (e.g., anger toward the defendant) mediated this relation. Finally, cognitive network representations of the case demonstrated that the RN and no-medical-testimony groups were similar and the SANE group was distinct from the other two conditions. We discuss these results in terms of the implications of SANE testimony in child sexual assault court cases.

A cross-sectional study on the effect of post-rape training on knowledge and confidence of health professionals in South Africa

OBJECTIVE

To determine whether a national training program on post-rape care in South Africa resulted in improvements in knowledge and confidence in health professionals, and to distinguish baseline factors related to these changes in knowledge and confidence.

METHODS

Data for this cross-sectional study were collected over four training sessions in 2008 using questionnaires and multiple choice question papers given to 152 health professionals. Information was collected on demographics, service provision, and previous training. The change in knowledge and confidence was calculated from baseline and post-training scores. Factors related to these changes in knowledge and confidence were tested through the development of two models.

RESULTS

Seventy-four percent of the health professionals (n=112) who attended the training had completed all components of the data collection. The average age of the professionals was 41.6 years, 71% were females, and 68% nurses. Health professionals showed significant increases in percentage knowledge (40% at baseline vs 51% post training; P<0.001) and confidence (67% at baseline vs 80% post training; P<0.001) after the training. In the final multivariate models, empathy was significantly associated with a change in knowledge (coefficient -1.2; 95% CI, -1.9 to 0.4; P=0.005), while the facility level and baseline knowledge and confidence were significantly associated with change in confidence.

CONCLUSION

The training program was found to improve levels of knowledge and confidence in health professionals. Rollout of this program is critical with expansion into undergraduate curriculums.

Sexual abuse of children in low-income settings: time for action

In this article, child sexual abuse in low-income settings is reviewed, including the extent of the problem, the way children present, and how they should be managed. Liaising with other agencies, training in all aspects of sexual abuse and creating an environment that is conducive to good care by all groups involved is essential. Technical details of medical examination are not covered as appropriate guidelines are accessible.