Social aspects of chain of evidence Dr Jan Welch King’s College Hospital

The Haven, Camberwell 24/7 sexual assault referral centre Opened May 2000, 24/7, for adults initially 12 boroughs of South London Part of Department of Sexual Health Provided in partnership with the Metropolitan Police 2 further centres opening 2004

STIs and rape STIs found in 4-56% of raped women Often reflect pre-existing infection Character denigration in court STI evidence seldom useful in the sexually active

STIs as evidence Likely to be relevant in: abused children sexually inexperienced adults or orifice the elderly

STI evidence and laws on disclosure Historical protection of Venereal Diseases Acts limited Identified infections may become available to courts Prophylactic antibiotics increasingly used

STIs as evidence: medico-legal considerations Choice of tests Management of the sample

Choice of tests Ideally: Well validated Capable of confirmation eg culture But newer methods (NAATs) increasingly used for eg chlamydia

Management of the sample Chain of evidence Storage of sample (ideally in duplicate at – 70 o ) Additional tests eg reference laboratory for typing Overseen by senior Ideally ‘M/L’ protocol agreed with clinicians

Case study: Lucy aged 8 Lucy presented to her GP with a discharge 5 days after a bicycle accident Genital swab sent to laboratory (no chain of evidence) Result: +ve for chlamydia

Lucy 2 Social services alerted Lucy taken into care Lucy assessed by community paediatrician and forensic medical examiner

Lucy 3 Lucy denies being abused Repeat swab taken for chlamydia Result: negative Lucy returns home

STIs in children Sexual abuse – always consider but also vertical transmission accidental transmission close non-sexual physical contact voluntary sexual activity

STIs in children - management Microbiology / GUM / paediatrics Screen for other infections M/L – chain of evidence and procedures Tests – predictive value in population Additional – biopsy / typing / cultures Reference laboratory Care with drugs

Case study – Saffron aged 4 15 th March  Childminder notices discharge on child’s underwear  GP treats for thrush and takes swab 22 nd March  Gonorrhoea culture positive - PPNG  Child given ciprofloxacin  Social services notified

Saffron 2 26 th March  Medical examination shows hymenal tear 7 th April  Child protection conference  Mother threatens to abscond to Jamaica  Saffron taken into police protection

Saffron 3 April  Mother and estranged father attend different GUM clinics for tests  Mother has PPNG (recent partner from Jamaica but he had no contact with child)  Father has fully sensitive strain of GC

Saffron 4 November  Proceedings heard in High Court  Father denied abuse  Mother shared bed, bath, towels and flannels with Saffron  Reference laboratory – typing showed father had unrelated strain

Saffron 5 November Decision by court  Evidence of abuse but father not implicated  Saffron returned to mother with support and supervision

STIs and evidence - summary May not be straightforward Diagnosis of an STI can have major implications M/L procedures useful but laboratory procedures crucial Need to determine role of new technologies Multi-professional considerations