NUMBER 13-19-00522-CR

COURT OF APPEALS

THIRTEENTH DISTRICT OF TEXAS

CORPUS CHRISTI – EDINBURG 

 

CASEY COX, Appellant,

v.

THE STATE OF TEXAS, Appellee.

 

On appeal from the 403rd District Court 

of Travis County, Texas.

 

MEMORANDUM OPINION

Before Justices Benavides, Hinojosa, and Silva

Memorandum Opinion by Justice Hinojosa

A jury convicted appellant Casey Cox of continuous sexual abuse of a child and 

sentenced him to eighty years’ imprisonment in the Texas Department of Criminal Justice. 

See TEX. PENAL CODE ANN. § 21.02. By one issue, Cox argues the trial court abused its 

discretion when it improperly admitted hearsay testimony under Texas Rule of Evidence 

803(4), the hearsay exception to statements regarding medical diagnoses and 
2

treatments. We affirm.

I. BACKGROUND1

Cox was charged by a multi-count indictment on May 9, 2018. Count 1 alleged that 

Cox committed the offense of continuous sexual abuse of a young child. See id. Counts 

2 through 7 alleged that Cox committed separate acts of aggravated sexual assault of a 

child. See id. § 22.021(a)(1)(B). Counts 8 through 11 alleged that Cox committed separate 

offenses of indecency with a child by contact. See id. § 21.11(a)(1).

A jury trial began on August 27, 2019. F.M.2, the complainant who was fifteen years 

old at the time of trial, testified that she was an infant when her mother and Cox began a 

relationship. Cox lived with F.M., her mother, and her younger sister (the child of Cox and 

her mother) in an apartment until F.M. was in seventh grade. F.M. considered Cox her

father—she testified that he taught her how to ride a bike, gave her lunch money, asked 

her about her daily activities, and they watched movies, played board games, and went 

to church together. Even though her mother and Cox ended their relationship when F.M. 

was approximately twelve years old, F.M. would still visit Cox at his apartment every 

Tuesday and every other weekend with her younger sister.

F.M. testified that she was about eight years old when Cox first sexually abused 

her. She recalled asking Cox about going to the doctor’s office. He told her that there was 

no doctor’s appointment but that he could perform a “checkup” on her. F.M. told jurors 

1 This case is before this Court on transfer from the Third Court of Appeals in Austin pursuant to a 

docket-equalization order issued by the Supreme Court of Texas. See TEX. GOV’T CODE ANN. § 73.001.

2 To protect the identity of minor children, we refer to the children by their initials or an alias. See

TEX. R. APP. P. 9.8(a).
3

that Cox took her into his room, laid her on his bed, removed her pants and underwear, 

spread her legs, put them on his shoulders, and used his finger to touch her vagina. F.M. 

remembered that when he had finished touching her, he told her to not tell anyone what 

happened. 

After that initial occurrence, Cox began abusing F.M. frequently. F.M. testified that 

Cox had sexual intercourse with her approximately “one hundred” to “two hundred” times.

She also stated that she performed oral sex on him, and he performed it on her. F.M. 

stated that Cox threatened to take away her pet if she did not comply with his demands. 

She also testified that she was scared Cox would turn his attention to her sister if she 

tried to stop him. 

The sexual abuse continued until Cox’s new girlfriend, Vivica Alvarado, moved into 

his apartment with him. Several months into their relationship, Alvarado suspected that 

Cox was cheating on her. In an attempt to determine whether Cox was faithful, Alvarado 

set up a cell phone in their bedroom to record Cox while she was gone. When she 

returned to the home later that day, she saw a video recording of Cox asking F.M., “Do 

you want to fool around?” and then saw him kiss F.M. Alvarado immediately turned the 

video off and confronted Cox. Although he first denied any wrongdoing, he later admitted 

to kissing F.M. After this admission, he apologized to both Alvarado and F.M.

Alvarado was not convinced that Cox only kissed F.M., so later that evening she 

watched the rest of the video. Alvarado testified that the video showed Cox lying on top 

of F.M. under the covers, moaning. When Alvarado confronted Cox again, stating she 

had proof that he had sex with F.M., she stated that he grabbed Alvarado’s cell phone, 
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broke it in half, and flushed the SIM card down the toilet. Alvarado did not call the police 

that night, but she spoke with F.M. and told F.M. that she was there when F.M. was ready 

to talk. 

A month later, F.M. told Alvarado that she was ready to talk. The next day Alvarado 

went with F.M. to school to report the sexual abuse. Cox was alerted to what was 

occurring and fled the city. He was later arrested in Fort Worth, Texas pursuant to a 

warrant.

After F.M.’s outcry, Dr. Katherine Snyder, a child abuse pediatrician and the 

medical director of the Child Abuse Resource and Education team at Dell Children’s 

Medical Center in Austin, Texas, performed a non-acute medical examination on F.M. At 

trial, the State offered Dr. Snyder’s medical report into evidence without objection and 

then began questioning her regarding her notes. Dr. Snyder reported that F.M. recalled 

penile-oral, penile-vaginal, and penile-anal penetration with Cox, causing anogenital pain 

and genital bleeding. As relevant to this case, Cox contests the admission of certain 

portions of Dr. Snyder’s testimony regarding Cox’s requests to take videos or 

photographs of F.M. The following colloquy occurred at trial:

State: Did she ever mention if the defendant would try to take videos 

or photographs of her?

Dr. Snyder: She did.

Defense: Judge, I’m going to object to that as hearsay because that is 

not covered by the medical exemption [sic].

State: It is actually part of the history in the medical chart.

The Court: It’s in the—is it in the report?
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Dr. Snyder: It is.

The Court: As part of your diagnosis?

Dr. Snyder: Yes.

The Court: I will overrule since she says it’s part of the diagnosis.

Dr. Snyder: She said that he would try to do that but that she would not let 

him do that and told him that if he tried to do that, [s]he would 

tell—she would tell her mother to check his phone. And then 

she told me that [her] stepdad’s girlfriend at the time or exgirlfriend, I can’t remember, had set up a phone, like a hidden 

phone and that that was—

Defense: Judge, I’m going to object to this, too, because this is clearly 

not part of any kind of medical diagnosis.

The Court: I don’t think that—I think it is going far afield. I’m going to 

sustain that part of the objection as to that aspect.

Defense: I’d ask for an instruction that the jury disregard that question 

and partial answer.

The Court: Disregard the last question and answer. You are supposed 

to—like you didn’t hear it. So you can’t consider it for any 

purpose. Go ahead.

Defense: May we approach briefly on that quickly?

The Court: Sure.

(At the bench, on the record)

State: Just for the Court’s attention, that is in the medical records so 

we will have to redact that out, if you want, before that goes 

back to the jury. That’s all.

The Court: That’s fine. Yeah, you can take it out later and clear it up. But 

for the record, you’re agreeing to redact that aspect of it?

State: Yes.

The Court: Okay. So that will be done before the jury gets it.
6

The jury found Cox guilty of Count 1,3 continuous sexual abuse of a child, and 

sentenced him to eighty years of imprisonment. This appeal followed.

II. STANDARD OF REVIEW & APPLICABLE LAW

We review a trial court’s ruling to admit evidence under an abuse of discretion 

standard. See Martin v. State, 173 S.W.3d 463, 467 (Tex. Crim. App. 2005). Such a ruling 

is upheld on appeal “if it is reasonably supported by the record and is correct under any 

theory of law applicable to the case.” Willover v. State, 70 S.W.3d 841, 845 (Tex. Crim. 

App. 2002). Under this standard, a trial court’s ruling will be deemed an abuse of 

discretion only if it is so clearly wrong as to lie outside the zone of reasonable 

disagreement or is arbitrary or unreasonable. Taylor v. State, 509 S.W.3d 468, 472 (Tex. 

App.—Austin 2015, pet. ref’d) (citing Lopez v. State, 86 S.W.3d 228, 230 (Tex. Crim. App. 

2002)); State v. Mechler, 153 S.W.3d 435, 439 (Tex. Crim. App. 2005). This deferential 

standard of review requires appellate courts to view the evidence in the light most 

favorable to the trial court’s ruling and not substitute its judgment for that of the trial court. 

See Riley v. State, 378 S.W.3d 453, 458 (Tex. Crim. App. 2012). 

Hearsay is an out-of-court statement offered by a party to prove the truth of the 

matter asserted in the statement. See TEX. R. EVID. 801(d). Generally, hearsay is not 

admissible except as provided by the rules of evidence or statutory authority. See id. R. 

802. Rule 803(4), entitled “Statements for Purposes of Medical Diagnosis or Treatment,” 

provides an exception to the hearsay rule. Id. R. 803(4). This rule sets forth that a 

3 The jury charge instructed the jurors to abandon Counts 2 through 11 if they found Cox guilty of 

Count 1, continuous sexual abuse of a young child. See TEX. PENAL CODE ANN. § 21.02.
7

statement that is made for and is reasonably pertinent to a medical diagnosis or treatment 

and describes medical history, past or present symptoms or sensations, their inception, 

or their general cause, is admissible into evidence regardless of whether the declarant is 

available as a witness. See id. 

Rule 803(4) “is based on the assumption that the patient understands the 

importance of being truthful with the medical personnel involved to receive an accurate 

diagnosis and treatment.” See id.; Bautista v. State, 189 S.W.3d 365, 368 (Tex. App.—

Fort Worth 2006, pet. ref’d). The proponent of the statement to be admitted must show 

that the out-of-court declarant knew that the statement was made for a medical diagnosis 

or treatment. See Taylor v. State, 268 S.W.3d 571, 588–89 (Tex. Crim. App. 2008). The 

proponent must also demonstrate the declarant’s understanding that their statement must 

be truthful so that the medical provider can reasonably rely on their information. See id. 

at 589; see also In re C.B.L., No. 11-15-00227-CV, 2016 WL 5853196, at *2 (Tex. App.—

Eastland 2016, pet. denied) (mem. op., not designated for publication).

III. ANALYSIS

By his sole issue, Cox complains that the trial court abused its discretion when it 

allowed Dr. Snyder to testify that, during F.M.’s medical examination, F.M. stated that Cox 

wanted to take videos and photographs of her. Cox contends the State did not fulfill its 

burden in showing that that information was pertinent or necessary to the doctor’s 

diagnosis under Texas Rule of Evidence 803(4). See TEX. R. EVID. 803(4); Taylor, 268 

S.W.3d at 588–89. He also argues that the State did not carry its burden in showing that 

F.M. understood the importance of being truthful with the doctor. Taylor, 268 S.W.3d at 
8

589. Cox concludes that the admission of this information was “the only testimony 

admitted before the jury that suggested that [Cox] wanted to film or video F.M.” and this 

was “extremely damaging” and caused substantial harm.

The record, however, reflects that Dr. Snyder’s questions to F.M. during their 

encounter were aimed for the purpose of medical diagnosis and treatment:

State: And then based upon what you learn from the history and 

everything else, what do you do? 

Dr. Snyder: So it depends. Right? So I’m collecting information about what 

has brought you to the clinic and then at that point I may 

decide, okay, we need to do some images or I may decide, 

hey, we need to do some laboratory testing or I may make 

additional recommendations for follow-up. I may refer you to 

therapy or I may refer you to see another specialist if there are 

certain things going on. So it just depends on where I am at 

the end of the evaluation that I have completed what I do next.

F.M.’s disclosure to Dr. Snyder that Cox wanted to take photos or videos of F.M. 

was in the context of a medical examination. Texas courts have held that statements 

describing abusive acts are pertinent to medical diagnosis and treatment. See Beheler v. 

State, 3 S.W.3d 182, 189 (Tex. App.—Fort Worth 1999, pet. ref’d) (holding that rule 803(4) 

covered statements describing penile-anal and penile-oral penetration, and that the 

complainant thought defendant was “so sick” that he “made her want to puke” when he 

made her watch pornography); Turner v. State, 924 S.W.2d 180, 189 (Tex. App.—

Eastland 1996, pet. ref’d) (allowing the treating doctor to testify about the child 

complainant’s reports of penetration). “The object of a sexual assault exam is to ascertain 

whether the child has been sexually abused and to determine whether further medical 

attention is needed.” Beheler, 3 S.W.3d at 189. Of note, both F.M. and her mother testified 
9

at trial that F.M. was in weekly therapy due to the sexual abuse and trauma she endured 

from the father figure in her life. 

Cox further relies on In re C.B.L. to argue that the objected-to statements are not 

admissible under Texas Rule of Evidence 803(4) because F.M. was not made aware of 

the importance of being truthful in the history she gave the doctor. See In re C.B.L., 2016 

WL 5853196, at *3. Cox’s reliance on In re C.B.L. is misplaced. The “crucial issue” in In 

re C.B.L. is whether Texas Rule of Evidence 803(4) applies in the context of a nonmedical examination. See id. at *2 (holding that this hearsay exception applies to 

therapists as long as the statement is made for medical reasons, and noting that courts 

have applied the exception to statements revealed to licensed professional counselors, 

social workers, paramedics, and psychologists, among others). Moreover, we note “there 

is no requirement that a witness expressly state that the hearsay declarant recognized 

the need to be truthful in her statements for the medical treatment exception to apply.” 

Beheler, 3 S.W.3d at 188–89. Instead, the reviewing court must look to the record to see 

if it supports a conclusion that the child understood why she needed to be honest when 

speaking to the caregiver. Id. Upon review of the record, Dr. Snyder testified that what 

F.M. told her during the medical examination “was very similar to information that was 

disclosed during the forensic interview, and so [Dr. Snyder’s] diagnosis was that this was 

consistent with the diagnosis of sexual abuse.” F.M.’s recollection was consistent, arguing 

in favor of her veracity. In addition, at the conclusion of F.M.’s testimony at trial, when she 

was asked, “Is everything you said here true?”, she responded, “Yes.” In light of the 

foregoing, we conclude the record supports that F.M. understood the need to be truthful 
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to her physician.

Lastly, even assuming without deciding that the admission of Dr. Snyder’s 

testimony regarding Cox’s desire to take photographs or videos was error, we cannot say 

it was harmful. See TEX. R. APP. P. 44.2(b); Gonzalez v. State, 544 S.W.3d 363, 373 (Tex. 

Crim. App. 2018). “Any error in admitting evidence is cured where the same evidence 

comes in elsewhere without objection.” Duncan v. State, 95 S.W.3d 669, 672 (Tex. App.—

Houston [1st Dist.] 2002, pet. ref’d) (citing Hudson v. State, 675 S.W.2d 507, 511 (Tex. 

Crim. App. 1984)). Dr. Snyder’s written medical report was offered into evidence as 

State’s Exhibit 11 without redaction and with no objection from the defense before the 

State began questioning her about its contents. 4 In the medical record, Dr. Snyder 

recorded that F.M. recalled "he [Cox] would try to get photo/videos, but she always 

refused and told him if he did, she would have her mother search his phone.” 

The erroneous admission of evidence is generally considered non-constitutional 

error subject to harm review under Rule of Appellate Procedure 44.2(b). See TEX. R. APP.

P. 44.2(b). Under Rule 44.2(b), error is not harmful unless it affects the defendant’s

substantial rights. See id.; Walters v. State, 247 S.W.3d 204, 218–19 (Tex. Crim. App. 

2007). The defendant’s substantial rights are affected if the error had a substantial and 

injurious effect or influence on the jury’s verdict. Rich v. State, 160 S.W.3d 575, 577 (Tex. 

Crim. App. 2005). In assessing whether the error affected the defendant’s substantial 

rights, the reviewing court examines the record as a whole. Motilla v. State, 78 S.W.3d 

4 Cox acknowledges as much in his brief, noting that “a review of State’s Exhibit 11, the child’s 

medical records[,] show that the redaction ordered by the trial court was not done. Unfortunately, trial 

counsel did not object to the State’s failure to redact the medical records . . . .”
11

352, 355 (Tex. Crim. App. 2002). If, after doing so, the reviewing court has fair assurance 

that the error did not influence the jury or had but a slight effect, the error did not affect 

the defendant's substantial rights. Id. Here, in light of the detailed testimony from F.M. 

and Alvarado, as well as the fact that the medical report had already been entered into 

evidence without objection, we conclude that Cox’s substantial rights were not affected.

“The law in Texas requires a party to continue to object each time inadmissible 

evidence is offered.” Ethington v. State, 819 S.W.2d 854, 858 (Tex. Crim. App. 1991). 

Because Cox did not object to the admission of Dr. Snyder’s written medical report which 

documented these allegations, her subsequent verbal testimony regarding Cox’s desire 

to video and photograph F.M. was thus cumulative and not harmful. See TEX. R. APP. P.

44.2(b). We overrule Cox’s sole issue.

IV. CONCLUSION

We affirm the judgment of the trial court.

LETICIA HINOJOSA

Justice

Do not publish.

TEX. R. APP. P. 47.2 (b).

Delivered and filed on the

27th day of May, 2021.