Medical Testimony:
How to explain a normal examination
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Explanation
1. Definitions
2. Importance of the history
3. Disclosure
4. Behavioural changes
5. Resilience and repair of tissue
6. Healing without residual clinical signs
7. The mindset of the perpetrator
8. The dynamics of the acts
9. Lack of DNA
10. The significance of the medical assessment in the bigger picture
1
Definitions
THE DEFINITION OF CHILD ABUSE
Sexual activity with a child when there is an imbalance in power
-Faller
Sexual
activity change, sexualised
Suspected: Signs and symptoms,
behavioural
behaviour, etc.
Non-contact: Sexual grooming, child pornography, witness of sexual
acts, flashing, etc.
Contact: Touching over the clothes, breasts, male genitals, anus,
inappropriate kissing, masturbation without penetration…
Penetration
Child Sexual abuse ≠ Penetration/rape
Definition of rape
Legal definition/medical ability
Any person ('A') who unlawfully and intentionally commits an
act of sexual penetration with a complainant ('B'), (without
the consent) of B, is guilty of the offence of rape.
Summary:
Sexual penetration without consent
Definition of sexual penetration
• 'sexual penetration' includes any act which causes penetration
to any extent whatsoever by-
•
(a)
the genital organs of one person into or
beyond the genital organs, anus, or mouth of another person;
•
(b)
any other part of the body of one person or,
any object, including any part of the body of an animal, into or
beyond the genital organs or anus of another person; or
•
(c)
the genital organs of an animal, into or
beyond the mouth of another person,
Summary:
Penetration to any extent whatsoever into or beyond…
Interpretation of definition of female genital penetration
Explain
• External genitalia
• Labia majora (outer genital lips)
• Labia minora (inner genital lips)
• Vestibule (area enclosed by the labia minora in the adolescent/labia minora
anteriorly and labia majora posteriorly of the prepubertal child)
• Internal genitalia
• Hymen
• Vagina
• Uterus and adnexa
12/2/2016
11
The slightest: into or beyond
BEYOND
INTO
12
Describe
• External genitals
• Internal genitals
12/2/2016
Into
Beyond
13
2
Importance of the history
• History is 95% of the conclusion REF.Finkel)
• Children under 7 years cannot tell elaborate lies(REF)
• Fantasy is about something known to the child
• If told what to say, will not relay detail
Detail, clarity and consistency
• Detail
• Place/s
• Environment
• Smells
• Sensations
• What was said
• Relative positions, where were the hands…?
• Consistency
• With SAPS 308
• Social worker
• Referrals
• Records
• Collateral history
3
The process of disclosure
• Delay:
• Fear
• Safety
• Disruption of the family
• Harm to loved ones
• Bribery
• Threats
• Ignorance
• Love
• Guilt and shame
• Attention
• Feeling of belonging
• CSA Accommodation Syndrome (REF)
• Secrecy
• Helplessness
• Entrapment and accommodation
• Delayed, conflicted and unconvincing disclosure
• Retraction
• Depends on
• Language development
• Knowledge
• Anatomy (3 holes?)
• In/on?
• Whether what is happening, is wrong
• Vocabulary
• Understanding of words, sentences
• Cognitive development
• The interviewer
• The space
Prerequisites for disclosure
•
•
•
•
•
•
Safe space
Trust
Believe
Non-judgmental
Supportive
Reassurance
The skills of the practitioner
• Questions must be age-appropriate
• Caregiver should not give information when child is present
• Ask open-ended questions
• Do not suggest
• Choice to show with dolls, write or draw
Consistency
• Incremental disclosure
• Smaller details may change
• The core stays the same
4
Importance of sexualised behaviour
Normal and abnormal sexual behaviour
• Normal
• Masturbation
• Curiosity
• Questions
• Response to directions
• Abnormal
• Compulsive
• Force/coercion
• Hurt others and self
• Indiscrete (Despite directions)
5
Resilience of Tissue
• Human tissue has resilience
• Elasticity
• Individual variation
• Human tissue heal through granulation
• Fast in children
Oestrogenisation
(adolescent)
Effects of oestrogenisation on genitalia
• External genitalia
• Increase in size
• Fatty deposition
• Hair (Adrenal Androgens)
• Vagina
• Thicker epithelium
• Lower pH
• Lubrication
• Hymen
• Elasticity
• Sensitivity
• Colour
• Possibility of pregnancy
Oestrogenisation: Elasticity
• Thicker
• Less sensitive
• Elastic
• Folds
• Prevents injury (Tears and clefts)
• Hides injury
• No research that a relaxed hymen cannot accommodate
penetrating object
Oestrogenisation: Lubrication
• Physiological discharge
• Human Sexual Response
• Physiological and may be active in non-cooperative penetration.
• (Also relaxation, pelvic tilt)
6
Perpetrator factors
Categories of abusers
• Paedophiles: fantasies about sexual activity with children
• May or may not act on desire
• Situational perpetrators
• Prefer adults
• Children available and vulnerable
• Mostly family members or acquaintances
• Want access
• Do not want to be caught out
• Do not leave evidence
• Power/aggression
Grooming
• Trust of child
• Access to the child
• Prevention of disclosure
• Disclosure not believed
I did not do it
Positions of trust
•
Parents
•
Stepparents
•
Family
•
Religious
•
Coaching
•
Camps
•
Teachers
•
Crèches
•
Homework groups
•
Children’s homes
•
Paediatricians
•
Nursing
•
Babysitters
•
Social workers
•
FCS
•
Spouses of these
•
???
7
Dynamics factors
• Penetration of external genitalia
• Penetration of anus
• Masturbation
• Coitus interfemora
• Oral penetration
• Anal penetration
• Hymen extremely sensitive
• Part of the grooming process
8
Healing
Healing
• Complete healing possible
• External genital injuries
• Hymenal injuries
• Anal injuries
• Oral injuries
• Extragenital injuries
9
Lack of DNA evidence
• Immature genital tract
• Vagina 1 cm long
• No sperm pool
• Dynamics
• External genitals
• Ejaculation outside body orifice
• No ejaculation
• Sexual dysfunction (GROTH, JONES)
• More likely from bedding and clothing
• Less than 9 hours for children younger than 10 years
• Unlikely after 24 hours if older than 10
• Best interest of the child
Absence of Semen/DNA
•
Visibility of semen (liquefacation)
•
Ejaculation may have been absent, premature, retarded or retrograde. (sexual dysfunction common)
•
No penetration
•
Change of posture
•
Movement
•
Delay of the examination
•
No ejaculation
•
Ejaculation took place outside a body orifice
•
Cleansing procedures
•
Abusive incident has been interrupted
•
Condom use
•
The perpetrator may be in the refractory phase after recent ejaculation
•
Child perpetrator
•
Orchidectomy
•
Conditions that may influence the production of spermatozoa such as mumps
•
Azoospermia
•
Vasectomy
•
Alcohol and marihuana use
•
Semen may have been too little to be able to detect DNA.
10
The evidentiary value of the medical assessment
Clinical assessment-one small piece of the puzzle
• Witnesses
• Collateral history
• Behaviour
• Social worker interview
• Forensic assessment
• Laboratory findings
• Crime scene
• Records
• Official police statements
• Interview with prosecutor