B9. Sexual Abuse Facilitated by Alcohol and Drugs
These recommendations are for pediatric examiners and other involved entities for responding to child sexual abuse that is/is suspected of being facilitated with alcohol or drugs.
Recognize there are multiple ways in which the use of alcohol or drugs may contribute to an act of sexual abuse against a prepubescent child. Perpetrators may overtly or surreptitiously use alcohol, “drugs of choice” in drug-facilitated sexual violence, such as rohypnol and gamma hydroxy butyrate (GHB) and other illegal drugs, as well as prescription and over-the-counter medications such as antihistamines, anticholinergics, and antitussives (Bechtel & Holstege, 2007). They may seek out children who have used substances (e.g., a child who was sex trafficked may routinely be given substances).
Children may be intentionally sedated using alcohol and drugs specifically to facilitate sexual abuse. Caregivers may also sedate children to “knock them out” during a party, when going to work, etc., which leaves children at greater risk for abuse and neglect. Children may or may not be aware that alcohol or drugs have been administered.
Substances may be used to induce drowsiness and deep sleep (Bechtel & Holstege, 2007) or cause hypnotic, amnesic, even mentally clouded or dulled response to prevent the child from resisting or having any recollection (Bechtel & Holstege, 2007; Spiller et al., 2007). For example, children used in pornography may have no recall of the sexual abuse depicted in photographs or on video/film (Spiller et al., 2007). Note that it is important during medical forensic care to avoid showing these photographs or videos/films to children as it could cause a highly traumatic response.
Children may live or spend time in clandestine drug houses and be exposed to drug cultivation, manufacturing by-products, use, sale, and distribution (often called “drug-endangered” children).
An example of such an environment is a methamphetamine laboratory. Caregivers’ substance misuse can interfere with their ability to provide a safe and nurturing environment for their children (National Alliance for Drug Endangered Children, 2015). In these situations, there is an increased risk of child abuse and neglect, including sexual abuse (National Alliance for Drug Endangered Children, 2015).
Older prepubescent children may experiment voluntarily with alcohol and drugs, especially if they live or spend significant time in an environment where they have access to these substances.
The cognitive and physical impairment associated with substance use alone (see Russell, 2008) makes these children in particular easy targets for sexual predators. As noted by Lisak (2005), perpetrators of sexual violence in general have become extremely adept at identifying vulnerable individuals and exploiting their vulnerabilities.
Educate responders on appropriate practices for responding to prepubescent child sexual abuse cases where alcohol and/or drugs are suspected to be involved, as per jurisdictional policy. If they do not already exist, agency/facility and multidisciplinary response team policies should be developed to guide immediate response to various scenarios involving suspected alcohol-or drug-facilitated sexual abuse of children. Note that jurisdictions may have interagency protocols to respond to cases involving drug-endangered children. Health care personnel also need to adhere to facility policy regarding (1) asking patients about alcohol and drug use in the course of intake and treatment; and (2) testing for alcohol and/or drugs if deemed medically necessary. They also need to know lab facilities designated by the jurisdiction for toxicology testing for forensic purposes and their collection and preservation policies.
Be aware that routine toxicology testing is not recommended in prepubescent child sexual abuse cases. However, the possibility of alcohol or drug involvement in the sexual abuse should routinely be considered. The collection of toxicology samples may be indicated in situations including but not limited to the following (drawn from the Commission on the Standardization of the Collection of Evidence in Sexual Assault Investigations, 2013):
- If a child’s medical condition appears to warrant toxicology screening for optimal care (e.g., the child presents with drowsiness, fatigue, light-headedness, dizziness, physiologic instability, memory loss, impaired motor skills, or severe intoxication);
- If there is a suspicion that the child was or may have been drugged or exposed to alcohol or drugs (follow jurisdictional policies for testing when children are exposed to methamphetamine laboratories); and/or
- If there is a suspicion of alcohol/drug involvement (e.g., due to the child’s lack of recollection of events).
This information is gleaned in the course of the medical history taking and the examination and must take into account the child’s developmental level and time frame for collection of toxicology samples.
In situations where it is revealed there is voluntary use of substances by children, this fact should not diminish the seriousness of the sexual abuse. Responders should guard against dismissing such cases. They should be aware that children might be reluctant to disclose voluntary use due to a fear of being disciplined or discounted by a caregiver or legal authorities. Children and caregivers should be informed what actions, if any, could potentially follow such a disclosure.
If there is indication for toxicology testing, inform children and caregivers of the following (in a manner that is developmentally appropriate for children and linguistically appropriate for children and caregivers):
- The purposes of toxicology testing and that testing results will be shared with the investigative team;
- The ability to detect and identify drugs and alcohol depends on collection of toxicology samples within a limited time period following ingestion;
- There is no guarantee that testing will reveal that substances were used to facilitate the abuse;
- Testing may reveal other drugs or alcohol that patients may have ingested;
- Follow-up testing and/or treatment may be necessary if testing reveals the presence of drugs;
- Not having testing done when indicated as described above may negatively impact safety planning for the child, as well as the investigation and/or prosecution;
- Who will pay for toxicology testing (noting testing done as part of forensic evidence collection typically may be paid for by a involved government entity); and
- When and how children and caregivers can have access to the results of the toxicology tests.
Collect toxicology samples as indicated. The child’s urine and blood can be tested for toxicology purposes, if collected within the time frames indicated for testing, as discussed in the following list. Other samples may be sought depending on case circumstances. Some additional issues to be aware of are noted below.
- The length of time that alcohol and drugs remain in urine or blood is affected by a number of variables (e.g., the type and amount of drug ingested, child’s body size and rate of metabolism, whether the child had a full stomach, and whether the child previously urinated) (American Prosecutors Research Institute, 1999). Urine is “the specimen of choice” for a toxicological investigation involving alcohol- or drug-facilitated sexual abuse as it allows for a longer window of detection of substances than does blood (LeBeau et al., 1999). The sooner a urine specimen is obtained after its ingestion, the greater the chances of detecting substances that are quickly eliminated from the body (LeBeau, 1999). Blood samples for toxicology purposes would be collected only during acute examinations; urine samples could potentially be collected during acute and nonacute care.
- Collect the first available urine within 120 hours of the abuse (SOFT, n.d.; UN Office on Drugs and Crime, 2011). The urine sample does not have to be a clean catch as bacteria in the urine will not compromise test results. If children cannot wait to urinate until arriving at the health care facility, first responders should ask them or caregivers to collect a sample and bring it to the facility, documenting the chain of custody. Law enforcement officers, emergency medical technicians, and child protective service responders should have specimen cups and instructions for collection readily available, according to agency policy. Ideally, patients should not urinate until after evidence is collected. However, the number of times that patients urinated prior to collection of the sample should be documented.
- Collect a blood sample if it is within 24 hours since the abuse (SOFT, n.d.). It may pinpoint the time when drugs were ingested (American Prosecutors Research Institute, 1999). If a blood sample is collected for toxicology screening, it should be accompanied by a urine sample. If a blood-alcohol determination is needed, collect blood within 24 hours of alcohol ingestion, as per jurisdictional policy. If blood has already been taken due to suspected drug ingestion, that sample can be used to determine blood-alcohol level. Another sample usually is not required.
- Consider if there is a need to collect a hair sample, as it may be useful in situations where there is a considerable delay in reporting suspected alcohol/drug-facilitated sexual abuse and/or a concern about a child’s chronic exposure to drugs. Unlike urine or blood, hair may be able to confirm long-term exposure to drugs over a period of weeks to months after ingestion (Cooper, Kronstrand, & Kintz, 2012). Positive hair testing is not always associated with the act of sexual abuse as far as timing, but in the prepubescent population, it can indicate use of a nontherapeutic drug or drugs (De Jong, 2011).
- Consider if there are any other potential sources for toxicology testing. For example, containers that may hold drug residue or samples of the child’s vomit.
- Know toxicology sampling instructions for the designated toxicology labs used by the jurisdiction. For convenience, the guidance offered in B8. Evidence Collection is provided below (see B8. Evidence Collection for footnote references).
- Collect as soon as possible after the event, as drugs are quickly eliminated from the body.
- If collecting a urine specimen prior to other evidence, instruct the child not to wipe.
- Collect a minimum of 30 mL of urine (up to maximum amount that can be obtained).
- Refrigerate or freeze when stored, as per toxicology lab policies.
Toxicology Sampling Instructions
If alcohol- or drug-facilitated sexual abuse is suspected, collect within 120 hours of the abuse.
Appropriate sterile container with at least 1.5% sodium fluoride preservative
If alcohol- or drug-facilitated sexual abuse is suspected, collect within 24 hours of the abuse.
Alcohol-free prep pad/betadine swab, gray-top tube (contains preservatives sodium fluoride and potassium oxalate) or as per jurisdictional policy, and pediatric needle and blood tube
Collect maximum amount of venous blood allowable by weight of child per blood draw. Refrigerate when stored, as per toxicology lab policies.
In cases of delayed reports of suspected alcohol- or drug-facilitated sexual abuse and/or if chronic exposure to drugs is suspected, collect at least 4 weeks after abuse.
· Collection paper
· Collect at least two head hair samples (thickness of a pencil) by cutting hair as close to the scalp as possible.
· Store at room temperature, in a dry environment protected from light, as per toxicology lab policies.
If child vomits in a suspected alcohol- or drug-facilitated case, collect vomit samples.
If containers might have drug residue of drugs used to facilitate the sexual abuse, collect containers.
· Collection tool (e.g., spoon, eyedropper-type suction device, or other tool that is consistent with biohazard procedures)
· Collection container has a lid with a tight seal to prevent leakage and contamination
· Packaging for containers
· Collect vomit sample using collection tool. Place in container and seal. If vomit is on clothing, sheets, or other objects, put items in container and seal (OH Chapter of the AAP Committee on Child Abuse and Neglect, 2009).
· Follow toxicology lab policies for refrigerated or frozen storage.
· Containers with drug residues should be packed individually in order to avoid cross-contamination of biological samples.
· Follow toxicology lab policies on storage for dry and wet items.
If toxicology tests are needed purely for medical care, the exam facility lab typically performs these tests. If toxicology samples are needed for both clinical and forensic purposes, one sample can be collected for immediate evaluation by the exam facility lab and another for analysis by the identified forensic toxicology lab. Collect these samples at the same time to avoid further discomfort to children.
As mentioned in B8. Evidence Collection, keep toxicology samples separate from samples collected for the jurisdictional evidentiary kit and note that procedures for toxicology collection, preservation, and analysis may differ from that of other evidence analysis. Exam facility laboratories should not analyze forensic toxicology samples in suspected alcohol- or drug-facilitated sexual abuse cases. Instead, involved investigative agencies should identify forensic laboratories that can analyze toxicology samples (American Prosecutors Research Institute, 1999). Information about the identified labs (e.g., contact information; what specifically they test; and procedures for specimen collection, packaging, labeling, sealing, refrigerated storage, handling, and transfer to the testing site, including transportation and delivery) should be provided to investigating agencies, exam facilities, and examiners. As with any forensic evidence, the chain of custody must be maintained and documented.
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|B10. Sexually Transmitted Disease Evaluation and Care
 Hartley, Mullings, and Marquart (2013) found that in 9 percent of cases with victims from age 3 to 18, victims were given alcohol/drugs before the abuse. However, most involved adolescent victims.
 See Swetlow (2003).
 The Child Welfare League of America (2001) noted that children whose caregivers abuse alcohol or drugs are three times more likely to be verbally, physically, or sexually abused, and four times more likely than other children to be neglected. In addition to the risk of child maltreatment, drug-endangered children may face health risks caused by exposure to drug manufacturing (Bechtel & Holstege, 2007), witness and experience all kinds of violence, be sold or traded for drugs, and be used as decoys by drug dealers (National Alliance for Drug Endangered Children, 2015). They may be exposed to communicable diseases such as HIV and hepatitis C through exposure to needles used by IV drug users and to a range of STDs via sexual abuse (Grant, 2007). To survive, these children may resort to committing crimes such as stealing food and money and be trafficked for sex and labor (National Alliance for Drug Endangered Children, 2015).
 Note that children with a history of sexual abuse may be more likely to use alcohol and drugs than their nonabused counterparts (Harrison et al., 1997; Smith & Saldana, 2013).
 Note that while the SOFT time frame for blood collection is 24 hours after the sexual abuse, the UN Office on Drugs and Crime (2011) extends the time frame to 48 hours.
 See SOFT at http://soft-tox.org/dfcc for further guidance on toxicology sampling, as well as the UN’s 2011 Guidelines for the Forensic Analysis of Drugs Facilitating Sexual Assault and Other Criminal Acts at www.unodc.org/documents/scientific/forensic_analys_of_drugs_facilitating_sexual_assault_and_other_criminal_acts.pdf.