Evidence Collection in Acute Sexual Abuse Marilyn Kaufhold, MD, FAAP

Learning Objectives The participant will be able to: List the usual forensic specimens to be collected from an acute sexual abuse/assault victim. Explain how sexual assault evidence may be contaminated or lost before collection. Define the concept of “chain of custody.” Justify the importance of establishing a collaborative relationship between medical providers and the forensic laboratory.

Evidence Only collected in acute cases May corroborate victim’s history by… Linking AP to victim Linking victim to the scene Linking the AP to the scene Identifying the perpetrator by DNA recovery Lack of evidence may also corroborate the victim’s history With the advent of DNA analysis, semen evidence is fairly robust, provided there was sufficient sample present in the first place Sperm can be found inside the vagina for up to several days. Sperm might be found inside the cervix for up to several weeks. Semen deposited inside the rectum is generally gone within 24 hours and inside the mouth within 12 hours. Of course if a condom was used or ejaculation didn’t occur, it’s likely that semen won’t be found even if the exam is done just a few hours after the assault. Local practice may include collection of oral and rectal swabs even if the victim does not provide history of oral or anal contact

DNA Evidence Powerful investigative tool that has replaced former serology techniques Trace evidence (foreign hairs, debris) still collected - less frequently processed DNA evidence may be left of the victim’s body or at the scene Semen, saliva, blood left by suspect on victim’s body, clothing, bedding or other items from the scene Skin cells (fingernail scrapings) if the victim scratched the suspect

Three Categories of Evidence 1. Standard items Collect in all exams – typical sources of evidence in SA case 2. Evidence per patient history Patient tells of other contact that might yield evidence Examiner finds debris, etc. 3. Reference samples Informs lab to differentiate foreign material from patient’s own type of blood, hair, DNA, etc.

1. Standard Items All Prepubertal Adolescent Girls Boys Clothing Mouth X Mouth Fingernails Anal canal Pubic hair Vulva/ vestibule Vagina/ Cervix Penis/ scrotum Collection of standard items depends on pubertal status and gender of the victim. Items are listed because they are the most typical locations for useful evidence to be deposited n sexual assault/abuse cases.

2. Evidence per Patient History/Exam Possible saliva – any site with oral contact (usual sites: perioral, neck, suction injuries, bite marks, breasts, abdomen) Possible semen (usual sites: face, abdomen, hands, external genitalia, legs) Rectum - Swabs per anoscope DFSA cases (Collect from perioral area, neck, breasts, abdomen) Debris (Vegetation, ligatures, intra-vaginal items [condoms, retained tampons], soil or sand, fibers, paint, hair [human,animal], other DFSA (drug-facilitated sexual assault): when the victim has no recollection of acts, perioral area, neck, breasts, abdomen are frequent sites of semen or saliva left by the perpetrator Anoscopy is indicated in cases in which the victim reports anal penetration or the medical provides sees anal injury or there is unexplained rectal bleeding. It may be done in adolescents who consent to the procedure. If there is concern about anal penetration in prepubertal children and the medical provider assesses the child needs a rectal exam, it should be done under anesthesia by a pediatric specialist.

3. Patient Reference Samples Head hair Pubic hair DNA sample: blood, buccal swabs These are required to differentiate the victim’s DNA from any other DNA collected from the body of the victim or the scene

Working with the Forensic Lab There are a number of different evidence collection protocols and kits Important to work with local/regional crime lab to establish consistent practice Best practice has not been determined in many cases Meet with local crime lab regularly Regular meetings with the crime lab promote Better evidence collection by medical providers Better appreciation of the medical provider’s task by forensic technologists

Prior to the exam, biological forensic evidence may be lost by… Rapid biochemical degradation Loss of sperm motility and morphology Gravity drainage from the vagina Mechanical loss: washing, brushing teeth, urinating, defecating, wiping, douching, etc. Pre-hospital providers should make every effort to get patient to the exam site before evidence is lost

Remember to obtain relevant history Time interval since assault Sexual acts Condom or other contraception Prior or subsequent sexual activity Post assault hygiene: urination, defecation, bathing/showering/washing, douching, eating/drinking, brushing teeth/gargling, changing clothes

Before starting… Make sure victim is medically stable Set up evidence kit items Pre-label where possible Sufficient supply of patient labels Supply of paper bags, evidence sealing tape Extra tubes, envelopes Supplies to collect foreign materials Post-its, tweezers, swabs, bindle paper Urine containers Supplies for drawing blood

If alcohol/drugs have been used to overcome the victim… Collect toxicology specimens If patient appears under the influence If there is a recent history of drug or alcohol use If patient has history of loss of consciousness Collect at the outset of the exam as specimens will more accurately reflect patient’s level of intoxication at the time of the assault

Avoid Evidence Contamination Contamination of evidence can lead to errors in interpretation of the crime circumstances Process only one patient at a time Clean exam environment after each patient Avoid coughing or sneezing or chewing gum - May deposit examiner DNA on patient and/or evidence Always wear gloves. Change gloves as needed during exam Routine cleaning of the exam room and stationary equipment is mandatory after or just before the forensic exam Disposable supplies and equipment should never be retained or re-used

Clothing Collection Collect, dry, and store correctly Body fluid stains on clothing are stable for years May yield more evidence than body Collect, dry, and store correctly Worn during assault or put on immediately after Underwear put on even after bathing - may contain semen from gravity drainage Collect clothes when… Bedding/linens collected by police at scene Christian (2000) Medical record review of 273 <10 yr old children who had ED exams and forensic evidence collected and processed between 1991-1996 in Philadelphia Findings Majority of forensic evidence (64%) found on clothing and linens Beyond 24 hr, all forensic evidence was found on clothing and linens Only 35% of children had clothing collected Recommendation: Remember to collect clothing

Step 1: Clothing Collection Wear gloves throughout clothing collection Use gloves throughout physical exam Prevents contamination of evidence with examiner’s DNA

Step 2: Clothing Collection Place 2 large pieces of paper on the floor for the patient to stand on while undressing Can use exam table paper Top paper will catch any debris or fibers that fall from patient while undressing undressing

Step 3: Clothing Collection Patient removes shoes …and steps onto paper

Step 4: Clothing Collection Examiner inspects clothing while still on patient for… Stains Debris Damage (tears, missing buttons, etc. Examiner asks if due to assault or not, and records

Step 5: Clothing Collection Patient removes clothing item by item Patient hands to examiner who places in labeled paper bag

Step 6: Clothing Collection Patient continues to remove clothes over the paper Patient puts on gown and steps off paper

Step 7: Clothing Collection Over the paper, examiner inspects for dry or wet stains Should avoid excessive handling Never use plastic bags Biological evidence will degrade

If Clothing is Damp… Fold item loosely to avoid transferring damp area to another area of item Don’t fold clothing across stains Damp areas will dry in paper bags

If Clothing is Wet… Wrap wet evidence in paper and place in bag Even in plastic bag Mark bag clearly Notify law enforcement if there are “wet evidence” bags Law enforcement will dry wet evidence before impounding it If left wet, biological degradation occurs The examiner may choose to use a plastic bag to place very wet evidence in so it will not leak through a paper bag and contaminate other evidence. If a plastic bag is used, the transporting officer should be advised that the contents need to be dried as soon as possible and then stored in a paper bag. Criminalists will know this but transporting officers do not always.

Step 8: Clothing Collection Seal bag: Fold top over. Tape should go over the fold and around the other side. Label outside of bag with… patient’s name examiner’s name date/time contents Write initials across seal This procedure is used because after sealing, it is not possible to tamper with the evidence without notice.

Step 9: Clothing Collection Carefully fold the top sheet of paper into a “bindle” Seal and label the bindle. It may contain debris from the clothes.

Step 10. Clothing Collection Discard the bottom sheet of paper It will be contaminated with debris from the floor

Clothing Collection: Finished! Place the bindle and the individually-bagged garments into a large paper bag The large paper bag usually does not need to be sealed. It is just used to carry all the smaller bags.

Other Collection Techniques

Head Hair and Fingernail Scrapings Head hair reference sample: Pluck/cut 20-30 hairs close to the scalp showing variations in length and color Fingernail scrapings: Suspect skin cells, body fluids, semen Use clean toothpicks Separate bindles, R or L If no fingernails, swab fingers down to knuckles Head hair is collected from the victim as a reference sample. Most forensic labs allow the hair to be cut close to the scalp rather than plucked. Fingernail scrapings are inportant if the victim scratched the suspect and may have skin cells under the nails. Specimens may be placed in prelabeled envelopes or bindles. Instructions for bindle on next slide.

Instructions for Making a Bindle 7. Fold in half. Seal the open end of the bindle. Initial over the tape. Lable contents. A bindle is a simple method of folding paper to create a collection packet for evidence (debris, vegetation, other) Training activity: pass out pieces of paper so participants can practice making a bindle.

Instructions for Collecting Swabs For wet stains, use dry swabs. For dry stains, use swabs moistened with de-ionized water Use 2 swabs. Rotate them to coat evenly with the available material Use at least two swabs for each site (Later, defense can request half the kit for tests by independent lab) Pairs of cotton tipped swabs are the usual tools for collecting samples of possible DNS.

Instructions for Evidence Handling Dry all wet swabs in a stream of ambient air for at least 60 minutes Make bindles to hold debris of various kinds Label all swabs and evidence collected: As swabs are collected, they should be placed, tips up, in a prelabeled rack to ensure they do not become mixed-up as to site source or contaminated. Patient name, dob Date and time of collection Contents Examiner initials

Oral Cavity Evidence Swab areas in red Purpose: Recovery of sperm, foreign material Procedure Collect 2 oral cavity swabs up to 12 hr post rape Wet or dry secretions/stains around mouth Any foreign material in or around mouth Optional use of dental floss may recover sperm from between teeth If an oral act occurred, the swab collection should proceed as soon as that history is obtained. Normal movement of tongue and lips (swallowing, speaking, etc) causes loss of evidence. Patient may be thirsty or hungry by time of arrival at exam site; collect oral cavity specimens first. Then patient is permitted to eat, drink.

Alternate Light Source: Locating Body Fluids Dried on the Skin Scan entire body with alternate light source. Identify areas of fluorescence Remove with water-moistened swab Remember: Substances other than semen and saliva fluoresce An ultraviolet light may be used to scan the body. The room needs to be darkened in order for potential semen dried on the skin will show up. The fluorescent material is then removed with moistened cotton-tipped swabs.

Removing Fluorescent Material 2 3 1 Arm - dried secretion not visible Arm – dried secretion fluoresces under UV light As fluorescent area is removed with moistened swab, fluorescence transfers to swab

Swabbing for Saliva Collect areas of possible saliva using swabs moistened with deionized water Bite marks Suction marks (hickeys) Per patient history DFSA

Genital Exam Sequence for Teen Girls Scan ext. genitalia w/alt. light source Cut matted pubic hair Pubic hair combing Inspect vulva and vestibule: Collect external specimens, debris Apply TB dye Speculum exam of vagina. Collect specimens. Collect endocervical specimens Document injuries in all areas as you proceed specimens Examination of adolescent girls is the most extensive and has more steps than prepubertal girls or boys or adolescent boys. This slide lists all the steps in the order they are best accomplished. Subsequent slides describe evidence collection for each in more detail.

Pubic Hair Collection: 3 Parts Cut out matted hair or crusted material Put in a bindle Brush/comb hair downward over clean paper under victim’s buttocks Fold paper with comb inside to make a bindle Reference standard 20-30 hairs are required from random areas - Pluck/Cut as close to skin as possible Label per general instructions #2 will capture any loose hairs, fibers, debris, etc., that have been transferred from the crime scene or from the assailant as previously discussed If pubic lice are noted on the victim, collect and submit. They may be able to be linked to the suspect by DNA. Criminalists prefer plucked hair. Cut hair can be submitted. If plucked hair is critical, it can be obtained later.

Collect Debris, if present from Vulva, Vestibule Inspect carefully Photograph in place Collect debris, vegetation, hairs, fibers using post-its, tweezers, swabs Place in a bindle Label Debris can sometimes be used to corroborate the location of the sexual assault.

Collect 2 swabs each from the vulva and vestibule Swab widely – include perineum

Collection from Vagina Insert speculum into vagina If no speculum, can collect blind Collect foreign material, if present Tampon, condom, hair, vegetation Photograph, document Collect 4 swabs from the vaginal pool Preferred: All swabs at same time. Rotate to coat evenly. If not all at one time, note how done Label swabs - code by number. Noting code number, prepare one dry mount and one wet mount slide Only water should be used to moisten the speculum since lubricant may affect the evidence When examining for injury, inspect for the presence of visible evidence The vaginal pool is in the posterior fornix – red X marks the spot.

Wet Mount Slide for Motile Sperm Detection Alternate methods When the speculum is removed from the patient’s vagina, add a drop or two of normal saline, agitate slightly to mix, dump the liquid onto the slide and cover with a cover slip - or - When the swabs are removed from the vagina, take one and roll it on the slide. Add a drop or two of normal saline to the slide and place a cover slip over the specimen. Examine immediately for motile/nonmotile sperm. Submit with other evidence.

Specimens from Cervix Obtain two swabs from endocervix Make sure to label “cervix” Not possible unless cervix is visualized

Looking for Sperm Sperm recovery confirms sexual contact Stained slides (crime lab) will detect sperm more often than the wet mount slide Wet mount only opportunity to see motile sperm Sperm survive longer in cervical mucus than in vaginal pool

Sperm Recovery in Living Victims Body cavity Motile Sperm Non-motile Vagina 6-28 h 14 h – 10 d Cervix 3-7.5 d 7.5 – 19 d Mouth - 2 – 31 h Rectum 4 – 113 h Anus 2 – 44 h Data refers to adolescents and adults, not prepubertal children. Data referencing other anatomic sites (mouth, rectum, anus) are from adult/adolescent studies, but may be applicable to children.

Microscopic Examination Focus, using a low power, 10-x Using a phase contrast microscope, change to 40+x Sperm motility decreases quickly with time and removal from vagina Without removing the cover slip, submit slide with evidence kit Phase contrast microscope

Sperm visualized with the aid of Christmas tree stain This slide is included just for another opportunity to see the morphology of sperm. The color is due to the stain used by the forensic lab. It is typical that the forensic will be able to detect sperm about three times more often than the medical provider because the stain makes the sperm more visible. The wet mount exam by the medical provider is, however, the only opportunity to see motile sperm. Sperm visualized with the aid of Christmas tree stain Prepared by the forensic laboratory

Prepubertal Female Genital Exam Sequence Alternate light source No pubic hair collection Swabs Vulva – swab widely Vestibule, if child cooperative Be careful not to touch the hymen Intravaginal ? – No need. If child goes to the OR for repair, intravaginal specimens can be collected under anesthesia Rest – same as teen This describes the usual sequence of collection for the prepubertal girl. Intravaginal swabs are not generally attempted in prepubertal girls If there is no hymen injury, it is not likely that, even if ejaculation occurred, sperm would be exclusively intravaginal. The hymenal opening is so small c/w the size of the penis that semen is more likely to be external and will be recovered from the vulva and vestibule swabs. Attempting intravaginal swabs is likely to cause the child pain because it is difficult not to touch the hymen when inserting swabs.

Male Genital Exam Sequence Prepubertal and adolescent same except for pubic hair collection. Alternate light source exam Collect 2 swabs, moistened with deionized water from... Penis, both glans and shaft Include coronal sulcus and base of penis Include foreskin if it retracts No swab from urethral meatus Scrotum Remind participants not to retract the foreskin if it doesn’t retract. Often the victim can be asked to retract the foreskin so the examiner can do the swabbing. Observe that there is no requirement or recommendation to take urethral swabs.

Anorectal Evidence Collection Same procedure for male and female Inspect and collect, if present... Moist/dry secretions, foreign material Clean the perianal area with 3 water-moistened 2x2s, back to front, prior to next step. Discard. Use buttock traction to expose anus to avoid contamination. Routinely collect 2 anal canal swabs by inserting the swabs cleanly into the anal canal. If anoscopy indicated (teens only), collect 2 swabs from rectal mucosa through anoscope Contamination of anal specimens may occur if vaginal secretions run down the perineum onto the anal folds. If this occurs, positive anal specimens cannot support a sodomy charge. That’s the reason for cleaning the anus prior to collecting the swabs. Collect even if history of assault does not include anal contact. Victims are often reluctant to report anal contact. When anoscopy is performed, obtain swabs by touching the swabs to the rectal mucosa above tip of instrument

Collect perianal debris using Post-its or a swab to brush debris into a bindle

Record all evidence collected… Documentation On diagrams and report Clothing Foreign materials, secretions on body Oral, genital, and anal samples Record results of vaginal wet mount Toxicology Reference samples Record all evidence collected…

Recommendations for Storage Storage of Collected Evidence Biological evidence once dried should be stored room temperature, refrigerated or frozen – follow crime lab recommendations Swabs and slides Trace evidence Reference samples Blood and urine should be refrigerated Do not freeze liquid blood samples Clothing should be stored in a dry area Storage recommendations will be influenced by local humidity and location of storage. It is critical to discuss with the forensic lab.

Chain of Custody Definition: chronological documentation showing the collection, custody, control, transfer, analysis, and disposition of physical evidence Medical provider collects, labels, and packages evidence specimens from the victim Law enforcement signs for and receives the evidence packet Crime lab signs for and receives the evidence packet from law enforcement

Questions?

References De Jong, A. R. (2011). Tests used to analyze forensic evidence in cases of child sexual abuse and assault. Child Abuse and Neglect: diagnosis, Treatment and Evidence. C. Jenny, Saunders: Elsevier: 112-117. (2001). California Medical Protocol for Examination of Sexual Assault and Child Sexual Abuse Victims. Sacramento, CA, California Emergency Management Agency