Guidelines for professional conduct in the care of child victims in institutes of legal medicine and forensic science

“There is no cause which merits a higher priority than the protection and development of children, on whom the survival, stability and advancement of all nations -and, indeed of human civilisation -depends”. World Summit for Children, 1990.

According to the UNICEF report “Hidden in broad daylight. A statistical analysis of violence against children – 2013”,¹ which presents the latest statistical data on violence against children based on information from 195 countries, violence remains a very real part of children's lives worldwide, although it is still under-documented and under-reported. When victims do file a complaint, unfortunately, the justice systems do not respond appropriately, and child protection services are inadequate or non-existent.

The findings and conclusions of the UNICEF report are a clear call to action, revealing that violence is a constant in the lives of children around the world from the most diverse backgrounds and circumstances. This violence not only causes children harm, pain and humiliation, but can also result in their death. In 2012, 95,000 children and adolescents under 20 years of age who were victims of homicide, making it the leading preventable cause of child injury and death. On average, 6 out of every 10 children in the world (about one billion) between the ages of 2 and 14 are regularly subjected to physical (corporal) punishment by their caregivers. Globally, more than one in three students aged 13-15 are also regularly bullied or harassed. Some 120 million girls worldwide (just over one in 10) have been victims of forced sex and other sexual assaults at some point in their lives. Boys are also victims of sexual violence, although to a much lesser extent than girls.

In Spain, during 2017, according to the Save the Children Foundation, with data based on official statistics, 38,433 children were victims of criminal offences.² Children are often victims of more serious and violent crimes than adults, crimes that cause more psychological and physical damage. Governments must take preferential action to prevent and eradicate these crimes. The percentages are higher in two crime groups: crimes against freedom and sexual indemnity (47.63% of the total number of victims of these crimes are minors) and crimes by family members (17.45% of the total number of victims are minors).

The United Nations Committee on the Rights of the Child included, in a report to the Spanish State, the recommendation to promote joint action protocols in cases of child abuse, as stated in the “Basic Protocol for Intervention against Child Abuse. Updated to intervention in cases of minors who are victims of gender violence. State Secretariat for Social Services and Equality, 9 June 2014”.³

The United Nations (ONU) recommendation is because child abuse, specifically, sexual abuse, is a complex social problem that requires multi-professional intervention from all the institutions involved, including the judicial and prosecutorial bodies, the State Security Forces and Corps (FFCCSSEE),the Health and Social Services, the National Institute of Toxicology and Forensic Sciences (INTCF) and the Institutes of Legal Medicine and Forensic Sciences (IMLCF). This is provided for under Directive 2011/93/EU on combating the sexual abuse and sexual exploitation of children and child pornography,⁴ which states that “Professionals likely to come into contact with child victims of sexual abuse and sexual exploitation should be adequately trained to identify and deal with such victims. That training should be promoted for members of the following categories when they are likely to come into contact with child victims: police officers, public prosecutors, lawyers, members of the judiciary and court officials, child and health care personnel…”.

The multi-professional conduct guidelines⁵ that we present here, was intended precisely to comply with this UN recommendation. This document was drawn up by the Medical Forensic Council (CMF) at the request of the Directorate-General for Relations with the Administration of Justice of the Ministry of Justice, and a working group was set up within the CMF.

The justification for this assignment is explained in Royal Decree 355/2014, of 16 May, which establishes and regulates the Medical Forensic Council, according to which the Council is constituted as a consultative and scientific-technical advisory body in the field of legal medicine and forensic science, whose ultimate purpose is to contribute to the achievement of a uniform and high-quality expert response by the various professionals entrusted with the function of supporting and assisting the operation of the courts and tribunals and the exercise of jurisdictional function.^6,7

From the start, on the CMF Scientific Technical Committee we considered that the document should be an enriched and participatory instrument, and if possible, agreed with the main groups with whom the IMLCF interact, inviting the participation of professionals involved in patient care, health and even non-health professionals, such as social workers. Thus, the guidelines for professional conduct in the care of child victims finally included the intervention of:

• 1)

  The Plenary of the Medical Forensic Council

• 2)

  The Spanish Association of Paediatrics

• 3)

  The Spanish Society of Social Paediatrics

• 4)

  The Association of Forensic Social Workers

• 5)

  The document “Healthcare Protocol on Child Sexual Abuse” being drafted by another working group in the area of the Community of Madrid, which includes paediatricians, hospital and SAMUR emergency doctors, forensic doctors and doctors from the Biology Service, Madrid Department of the National Institute of Toxicology and Forensic Sciences (doctors Amparo Fernández, C. Albarrán and L. Fernández de Simón). From this document we took the tables created by the abovementioned group of doctors from the Biology Service of the Madrid department relating to sample collection, of both forensic and medical interest. These were included in this protocol as annexes.

The objectives of the document were to develop basic guidelines for dealing with sexual abuse and other serious maltreatment of children, which are intended:

• 1.

  To contribute to updating the conduct criteria

• 2.

  To improve assessment

• 3.

  To respond to the need to strengthen inter-professional coordination within the IMLCF, and between professionals of these and other institutions involved, especially in interventions for the care of minors, and to prevent the consequences of secondary victimisation. In this regard, the collaboration between the CMF and the Spanish Association of Paediatrics and the Spanish Society of Social Paediatrics should be highlighted, due to the positive implications that can be derived from such coordination of conduct between healthcare professionals and legal and expert professionals.

• 4.

  To serve as a stimulus to promote the quality and safety of forensic and care practices, and to fill any gaps, would also be objectives.

The guidelines can also be used in a similar way for people with disabilities in need of special protection, art. 25 CP – as amended by LO 1/2015. Law 4/2015, of 27 April on the Statute on the Victims of Crime, to provide special and uniform protection to those in the same situation of vulnerability as children, and for the same reasons (with regard to their degree of mental maturity), as reflected in the aforementioned Law in Article 26, on “Protective measures for minors and people with disabilities in need of special protection”.⁸

With regard to the methodology used to draw up the guidelines, an extensive literature review of relevant publications was carried out, selecting the most significant articles or papers with the highest level of evidence. We monitored for possible updates until the last moment of the drafting, in order to convey the current scientific criteria. For example, it is worth mentioning that we monitored the Adams classification to assess anogenital findings in the context of suspected child abuse. This classification is widely accepted and is currently the main guideline for this assessment, since it is based on consensus, updated and continuously developed. The most recent version of the classification is that of 2018.⁹

At the same time, a review was undertaken of national and international protocols and guidelines that could contribute to the document.

In a long and complex document like this, it is difficult to highlight some of its aspects over others, but the following can be highlighted in very condensed form:

• 1.

  Its commitment to a comprehensive and multi-professional approach to the care of child victims, based on the principles (the child's best interests) and conduct criteria set out therein, distinguishing and explaining the care function and expert function of professionals, and how they coordinate with one another

• 2.

  The complete and comprehensive approach to “the evidence” in child mistreatment/abuse, widely developing not only the different aspects of medical-forensic conduct, but also guidelines and recommendations for the child's testimony, the development of pre-constituted and/or anticipated evidence, the expert report on the testimony, as well as the psychological and social-family indicators for the detection of child sexual abuse

• 3.

  The development of the content and formal aspects of the considerations and conclusions of the comprehensive expert report in the investigation of child sexual abuse.

• 4.

  The contribution of important guidelines and practical recommendations concerning the medical-forensic interview of minors, the assessment of physical examination findings in child sexual abuse (CSA) and, in a very broad and thorough way, it addresses everything concerning samples for complementary studies. In this regard, it distinguishes between clinical samples and expert samples and collects in a very detailed way everything related to the times of collection, actioning and conservation of samples. All of this is developed in 6 annexes.

• 5.

  Among many other specific aspects, the revision and updating of the conduct criteria are worth noting in the event of a recent or acute episode of sexual aggression to a child. Cases are distinguished where investigation into the sexual crime constitutes a medical/ legal emergency and must therefore be handled as such by the forensic and health services.

Finally, these guidelines are intended to be useful to all IMLCF and care professionals in their daily work, contributing towards achieving uniform and high quality care and expert response by the different professionals to these tragic situations. They are also intended to serve as a model and benchmark for other national and international institutions involved in the care of children.