14 Dry all evidence before packaging To dry swabs, place swabs in swab dryer, with cotton tip pointing upward to promote drying 15 Do not allow cotton tip of swabs to contact other objects or surfaces during drying process (Use the test tube rack not allowing it to touch any other swabs.) 16 After drying, swabs place in swab boxes and then into the envelopes provided for each specimen (If additional specimens were collected and no swab box or evidence envelope is available for packaging, dried swabs may be placed in a plain envelope.) 17 Label all envelopes and boxes with patient’s name, case number, date, and name of the examiner 18 Seal envelope: Do not lick envelopes to seal them Use a clean gauze or cotton and wet with sterile water to moisten adhesive on collection envelopes or seal the envelope with tape 19 All envelopes containing evidence specimens should be placed inside the evidence collection kit box The sealed bag containing underpants should not be placed inside the box; all other clothing bags should remain outside of the box Each item collected must be noted on the evidence receipt form Adapted from Forensic Exam Checklist, Children’s Hospital of Philadelphia, Philadelphia, PA With permission Drug-Facilitated Sexual Assault Alcohol or other drugs play an important role in many sexual assaults, whether voluntarily ingested by the victim, surreptitiously given by the assailant, or ingested under force or coercion Adolescents often report using alcohol and/or drugs immediately before a sexual assault Increasing rates of drug-facilitated rape have been associated with the availability of alcohol and benzodiazepines While “date-rape” drugs (e.g., flunitrazepam [Rohypnol], Υ-hydroxybutyrate [GHB], ketamine) have received much public attention, these are rarely identified as the offending agent Drug testing should be performed if a patient appears intoxicated, reports drugfacilitated assault, or cannot recall details of the assault In addition, patients should be reminded that even if drug use was voluntary, it is important to provide history of intoxication preceding assault Protocols with the toxicology laboratory at each institution are necessary as date-rape drugs and many other drugs of abuse are not included in standard drug-screening panels Pregnancy Testing Pregnancy testing should be performed on all pubertal females as well as all females >11 years of age STI Testing With rare exception, the identification of most sexually transmitted infections (STIs) in children beyond the neonatal period suggests sexual abuse Postnatally acquired gonorrhea (GC), chlamydia (CT), syphilis, and non–transfusion-acquired HIV are usually diagnostic of sexual abuse Sexual abuse should also be considered when genital herpes is diagnosed Although genital warts are found in sexually abused children, they can also be present in children in whom there is no suspicion of abuse due to the high prevalence of human papillomavirus in the population The possibility of sexual abuse must be investigated thoroughly if no conclusive explanation for nonsexual transmission of an STI can be identified The recommended action by the American Academy of Pediatrics (AAP) regarding the reporting of suspected child sexual abuse varies by the specific organism and is outlined in Table 127.4 The decision to evaluate STIs is made on an individual basis Most experts recommend that pubertal victims of sexual assault undergo STI testing as the prevalence of pre-existing asymptomatic infection in this group is high Therefore, although the identification of an STI may represent an infection consensually acquired prior to the assault, laws in all 50 states strictly limit the evidentiary use of a survivor’s previous sexual history, including evidence of previously acquired STIs, as part of an effort to undermine the credibility of the survivor’s testimony In addition, due to current testing methods using nucleic acid amplification (NAAT), STI tests have been found to be positive as a result of an assault even when obtained within 72 hours of the assault Alternatively, because the prevalence of STIs in prepubertal patients is quite low, occurring in less than 5% to 10% of prepubertal victims, the AAP and Centers for Disease Control and Prevention (CDC) recommend targeted screening in this age group It is recommended that prepubertal victims be screened for STIs if signs or symptoms of an STI are present; there is history and/or evidence of ejaculation or oral/genital penetration; the suspected assailant is known to have an STI; if there is a high community prevalence of STIs; or if the patient or parent requests STI testing Signs or symptoms of an STI include genital discharge or pain, genital itching or odor, urinary symptoms, and genital ulcers or other lesions If STI testing is obtained, testing should occur prior to the initiation of any treatment, and STI screening should occur after evidence collection is complete Furthermore, if a patient is thought to have an STI, tests should be sent for all common STIs Because of the legal and psychosocial consequences of a false-positive diagnosis, only tests with high specificities should be used (see discussion below) TABLE 127.4 IMPLICATIONS OF COMMONLY ENCOUNTERED SEXUALLY TRANSMITTED (ST) OR SEXUALLY ASSOCIATED (SA) INFECTIONS FOR DIAGNOSIS AND REPORTING OF SEXUAL ABUSE AMONG INFANTS AND PREPUBERTAL CHILDREN ST/SA confirmed Evidence for sexual Suggested action abuse Gonorrhea a Syphilis a HIV c Chlamydia trachomatis a Trichomonas vaginalis a Genital herpes Diagnostic Diagnostic Diagnostic Diagnostic Highly suspicious Highly suspicious (HSV-2 especially) Suspicious Condylomata acuminata (anogenital warts) a Bacterial vaginosis Report b Report b Report b Report b Report b Report b , d Consider report b , d , e Inconclusive Medical follow-up a If not likely to be perinatally acquired and rare vertical transmission is excluded should be made to the agency in the community mandated to receive reports of suspected child abuse or neglect c If not likely to be acquired perinatally or through transfusion d Unless a clear history of autoinoculation exists e Report if evidence exists to suspect abuse, including history, physical examination, or other identified infections HIV, human immunodeficiency virus; SA, sexually associated; ST, sexually transmitted Adapted from Kellogg N; American Academy of Pediatrics Committee on Child Abuse and Neglect The evaluation of child abuse in children Pediatrics 2005;116:506–512 b Reports For all patients, determination of which sites to sample is based on areas of possible contact with assailant’s bodily fluids and includes vaginal, urethral, anorectal, oropharyngeal, and/or blood As the history of the assault provided or recalled may change with time, the clinician should consider testing for STIs from multiple sources Nucleic acid amplification tests (NAATs) on urine specimens for GC, CT, and trichomonas have essentially ... transmitted Adapted from Kellogg N; American Academy of Pediatrics Committee on Child Abuse and Neglect The evaluation of child abuse in children Pediatrics 2005;116:506–512 b Reports For all patients,... nonsexual transmission of an STI can be identified The recommended action by the American Academy of Pediatrics (AAP) regarding the reporting of suspected child sexual abuse varies by the specific