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

2. 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

3. 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

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

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

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

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

9. 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

10. 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

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

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

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

14. 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

15. 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

16. 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

17. 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

18. 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

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

20. 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