Opinion ID: 729726
Heading Depth: 3
Heading Rank: 1

Heading: Rejected Medical Examination

Text: 102 Although the medical evidence was inconclusive and the examiners took no pictures, the district court denied defendants' requests for further medical examinations. This discretionary ruling is not error, but highlights the importance of the children's testimony and the prejudice to defendants caused by the court's refusal to admit Dr. Underwager's testimony. 103 Soon after these children were removed from their homes, the Department arranged for some of them to undergo a medical examination by Dr. Richard Kaplan, a pediatrician at the Yankton Medical Clinic who examines 500 to 600 children per month. Dr. Kaplan testified that the vaginal redness and possible trauma he observed could be consistent with abuse or any number of possible non-abuse causes; the conditions he observed were basically nonspecific as to cause; he could not conduct a thorough examination while the children were awake; and based on his limited examination, he could not positively diagnose any of the children as having been abused. 104 Thereafter, on February 11, 1994, his co-worker, Dr. Robert Ferrell, had the children placed under anesthesia and examined them with a colposcope. Although he had received some training in the sex abuse area seven years earlier while he was a resident, Dr. Ferrell had no special experience in sex abuse investigations. Dr. Ferrell had never testified in a criminal case. He did not take photographs of his colposcopic examinations, although the process would have been easy and helpful in this case. 105 Dr. Ferrell admitted that neovascularization (redness in the vaginal areas), decreased anal tone, and hymenal tags can be common place occurrences resulting from many different everyday occurring causes. He did make a post-operative diagnosis that F.R. indicated evidence of tearing and scarring of the anal mucosa but otherwise a normal anus and vagina; that R.R. had apparent damage to the hymenal ring consistent with vulvovaginal trauma, and possible anal trauma; that L.R. revealed a fusion and evidence of anal trauma; that J.R. had neovascularization, clue cells and a tag or scar on the hymen. On T.R., the anterior portion of the hymenal ring was essentially gone; he diagnosed vaginal and vulva trauma. 106 The defendants' pediatric expert, Dr. Robert Fay of Albany, New York, testified he had prior training and experience with Native American patients, sex abuse diagnosis and treatment, and that he had been previously retained by both defense and prosecution in other cases. In essence, Dr. Fay testified that the reported hymenal fusions in L.R., R.R. and J.R. are suspicious for sexually acquired trauma; that labial injury would be a significant finding in diagnosing sexual abuse, but that most of the conditions observed by the doctors offered by the prosecution -- such as redness, erythema, neovascularization, vaginal furrows and ridges, a gaping hymen, a hymenal notch, clue cells, relaxed anal tone, and anal folds, were of no significance in evaluating whether sex abuse had occurred, and are found in a high percentage of non-abused children. 107 Dr. Fay testified he felt Dr. Ferrell was not qualified based on training or experience to perform a colposcopic examination of a child; his training was outdated; photographic evidence in such cases is frequently dispositive, very helpful, and perhaps essential; and a further physical examination of the children would be very helpful. 108 The literature in this area, see Jan Bays & David Chadwick, Medical Diagnosis of the Sexually Abused Child, 17 Child Abuse & Neglect 91, 92, 95, 103 (1993), indicates that frequently findings on examination of children allegedly sexually abused are no different than similar findings on children who most likely have not been subject to sexual abuse. That work indicates that a number of factors or conditions may mimic findings caused by sexual abuse or wrongly produce a history suggestive of child sexual abuse, including adults misinterpreting normal masturbation or sexual play between children and a variety of other dermatologic, congenital, traumatic and infectious conditions. 16 Another leading article indicates 109 Even in our present state of knowledge, it is becoming increasingly evident that, as a consequence of naturally occurring physical changes, there will always be an overlap in findings between nonabused children and the victims of sexual misuse. The appreciation of this reality should serve as a constant reminder that the determination of sexual abuse can rarely rely on a physical examination alone and that consideration of all the components of the investigation -- especially the information obtained from the child -- is essential. 110 John McCann, M.D., et al., Genital Findings in Prepubertal Girls Selected for Nonabuse: A Descriptive Study, 86 Pediatrics 428, 438 (Sept. 1990). 111 We agree that, as a matter of discretion, the district court need not have required more invasive procedures on these small children. But we must observe that the medical testimony, while consistent with possible sexual abuse, is inconclusive in light of other matters discussed herein. In addition, some of that alleged trauma may have occurred from sexual interplay and activity between and among the victims and other young children. 112