                  IN THE SUPREME COURT OF THE STATE OF IDAHO
                                 Docket No. 46371


STATE OF IDAHO,                                       )
                                                      )
     Plaintiff-Respondent,                            )       Boise, November 2019 Term
                                                      )
v.                                                    )       Opinion Filed: February 24, 2020
                                                      )
DAVID LEE CHRISTENSEN,                                )       Karel A. Lehrman, Clerk
                                                      )
     Defendant-Appellant,                             )
                                                      )

        Appeal from the District Court of the Fourth Judicial District of the
        State of Idaho, Ada County. Michael Reardon, District Judge.

        The decision of the district court is affirmed.

        Nevin, Benjamin, McKay & Bartlett, Boise, attorney for Appellant.
        Dennis Benjamin argued.

        Lawrence G. Wasden, Idaho Attorney General, Boise, attorney for
        Respondent. Andrew V. Wake argued.




BEVAN, Justice
                                      I. NATURE OF THE CASE
        Dave Lee Christensen was indicted by a grand jury on five counts of lewd conduct with
two minors under sixteen. The State notified Christensen of its intent to introduce interviews of
the two alleged victims at trial under Idaho Rules of Evidence (“I.R.E.”) 803(4) and 803(24). At
a pretrial hearing, the district court ruled the interviews were admissible because the victims’
statements were made for purposes of medical diagnosis or treatment. The interviews were
admitted at trial by stipulation. A jury found Christensen guilty on four of the five counts.
Christensen appeals the district court’s admission of the interviews. We affirm.
                          II. FACTUAL AND PROCEDURAL BACKGROUND
        On May 30, 2017, A.M.O. told a peer tutor that Christensen, her step-grandfather, had
touched her inappropriately. That same day, A.M.O.’s twin sister, A.G.O., also told school
                                                  1
officials she had been inappropriately touched by Christensen. School officials reported the
information to the Meridian Police Department and Detective Jeff Miller was assigned to
investigate the allegations. After a brief investigation Detective Miller referred A.M.O. and
A.G.O. to St. Luke’s Children at Risk Evaluation Services (“CARES”) to be assessed.
       CARES is designed to provide evaluation and treatment of abused or neglected children.
A child can be referred to CARES by law enforcement, the Department of Health and Welfare,
the court system, or other medical providers. Once a child is referred, the child is assessed in
three ways: a forensic interview, a psychosocial assessment, and a medical examination. The
forensic interview is performed first by a social worker who is part of the medical team. It is a
structured conversation with the child in hopes of maintaining detailed information on something
the child has experienced or witnessed. The forensic interview adheres to the National Institute
of Child Health and Human Development (“NICHD”) guidelines designed to elicit disclosure
from children in a non-leading and neutral way. The psychosocial assessment, also performed by
a social worker, is completed after the forensic interview. The psychosocial assessment gathers
information related to the child’s psychological well-being and their social well-being. The last
step in the assessment process is the medical examination. The examination is a full head-to-toe
medical examination that commonly involves a detailed examination of the genitals and
evaluation for possible sexually transmitted diseases or infections. The medical examination is
informed by the forensic interview and psychosocial assessment to determine issues the child
may have, areas that may need extra focus, any clues about possible physical symptoms and any
ideas about possible infections or injuries.
       Lara Foster, a medical social worker at CARES, conducted the forensic interview of
A.M.O. on June 9, 2017. In that interview A.M.O. disclosed to Foster that she had been
inappropriately touched by Christensen. A.G.O. was interviewed by Foster on June 12, 2017.
A.G.O. also disclosed that Christensen had inappropriately touched her.
       On August 8, 2017, Christensen was indicted on five counts of lewd conduct with a
minor under sixteen. The State notified Christensen of its intent to introduce the CARES
interviews under I.R.E. 803(4) and 803(24). Christensen objected. At a hearing, the district court
held the CARES interviews were admissible under I.R.E. 803(4). The CARES interviews were
admitted by stipulation at trial. Both A.M.O. and A.G.O. testified at trial. A jury found


                                                2
Christensen guilty on four of the five counts of lewd conduct with a minor under sixteen.
Christensen timely appealed.
                                      III. ISSUES ON APPEAL
1.      Whether the district court abused its discretion by admitting the CARES interviews under
        I.R.E. 803(4).
2.      Whether the district court abused its discretion by admitting the CARES interviews
        without first redacting statements elicited by A.M.O. and A.G.O. from introductory
        questions, questions designed to build trust and rapport, and questions designed to test
        episodic memory.
                                    IV. STANDARD OF REVIEW
        “The trial court has broad discretion in deciding whether to admit hearsay evidence under
one of the exceptions, and this Court will not overturn an exercise of that discretion absent a
clear showing of abuse.” State v. Stanfield, 158 Idaho 327, 331, 347 P.3d 175, 179 (2015). This
Court reviews an alleged abuse of discretion by determining whether the trial court “(1) correctly
perceived the issue as one of discretion; (2) acted within the outer boundaries of its discretion;
(3) acted consistently with the legal standards applicable to the specific choices available to it;
and (4) reached its decision by the exercise of reason.” Lunneborg v. My Fun Life, 163 Idaho
856, 863, 421 P.3d 187, 194 (2018). “Even if evidence was admitted in error, this Court will not
grant relief if we find the error to be harmless.” Stanfield, 158 Idaho at 331, 347 P.3d at 179.
                                           V. ANALYSIS
        Christensen argues the district court abused its discretion by failing to consider whether
A.M.O. and A.G.O. understood that their statements were made for the purpose of medical
diagnosis or treatment. Christensen also argues that even if statements by A.M.O. and A.G.O.
were admissible under I.R.E. 803(4), the district court abused its discretion by admitting the
CARES interviews without first redacting statements elicited from introductory questions,
questions designed to build trust and rapport, or questions designed to test episodic memory. For
the reasons below, we affirm the district court’s admission of the CARES interviews in their
entirety.
A.      The district court did not abuse its discretion by admitting the CARES interviews
        under I.R.E. 803(4).
        Christensen first argues the district court abused its discretion by admitting the CARES
interviews under I.R.E. 803(4). Idaho employs the totality of the circumstances approach when
applying hearsay exceptions to children. State v. Kay, 129 Idaho 507, 518, 927 P.2d 897, 908

                                                 3
(Ct. App. 1996). This approach, when applied to the exception for statements made for the
purpose of medical diagnosis or treatment, permits courts to consider several factors that
establish a child made a statement which, though hearsay, would be admissible under Rule
803(4). Christensen asserts the district court did not act consistently with applicable legal
standards because it failed to consider these factors to determine whether the twins were
informed of or otherwise appreciated the importance of speaking truthfully to the CARES
interviewer.
       “Hearsay is an out-of-court statement offered in evidence to prove the truth of the matter
asserted.” Takhsilov v. State, 161 Idaho 669, 674, 389 P.3d 955, 960 (2016) (internal quotations
omitted). “Hearsay evidence is generally inadmissible unless it falls within an exception
provided by the rules of evidence or another rule promulgated by this Court.” State v. Hill, 161
Idaho 444, 448, 387 P.3d 112, 116 (2016). One exception exists for statements made for medical
diagnosis or treatment. See I.R.E. 803(4). A proponent must show the statement “(A) is made
for—and is reasonably pertinent to—medical diagnosis or treatment; and (B) describes medical
history; past or present symptoms or sensations; or their source.” Id. The first step of the analysis
thus requires the statements not only be made for the purpose of medical diagnosis or treatment
but also requires the statements be reasonably pertinent to that diagnosis or treatment. See Kay,
129 Idaho at 518, 927 P.2d at 908 (explaining a declarant must show: “(1) that the statements
were ‘made for purposes of medical diagnosis or treatment’; (2) that the statements described
‘medical history, or past or present symptoms, pain, or sensations, or the source thereof’; and (3)
that the statements were ‘reasonably pertinent to diagnosis or treatment.”). “[T]he evidentiary
rationale for permitting hearsay testimony regarding spontaneous declarations and statements
made in the course of receiving medical care is that such out-of-court declarations are made in
contexts that provide substantial guarantees of their trustworthiness.” White v. Illinois, 502 US
346, 355 (1992). Such statements are trustworthy because patients “seeking treatment will not be
inclined toward deception and fraud” as that deception or fraud would be against a patient’s vital
interest. See Gonzales v. Hodson, 91 Idaho 330, 332, 420 P.2d 813, 815 (1966).
   1. The district court’s admission of the CARES interviews under I.R.E. 803(4) was not an
      abuse of discretion because A.M.O. and A.G.O. made their statements for the purpose of
      medical diagnosis or treatment.
       The district court did not abuse its discretion by admitting the CARES interviews under
I.R.E. 803(4) because the totality of the circumstances here establishes the twins’ statements
                                               4
were made for the purpose of medical diagnosis or treatment. For guidance in making this
determination we turn to the well-reasoned analysis in Kay. In Kay, the Idaho Court of Appeals
addressed the precise issue presented here–whether a child is capable of making statements for
the purpose of medical diagnosis or treatment. 129 Idaho at 518, 927 P.2d at 908. There, the
district court admitted under IRE 803(4) statements made by a four-year-old victim to two
physicians during medical examinations describing what occurred when the victim was
molested. Id. at 517, 927 P.2d at 907. The defendant argued, like Christensen here, that the
prosecution failed to show that the four-year-old appreciated the importance of speaking
truthfully to the physicians. Id. at 518, 927 P.2d at 908. The court rejected this argument and held
that a child, even as young as four, can be motivated to give information for purposes of medical
diagnosis or treatment falling within the parameters of I.R.E. 803(4). Id. The court recognized a
“dilemma arises in attempting to apply to children evidentiary rules which were drafted with
adults in mind.” Id. But, to remediate the dilemma, the court held the district court should
consider the totality of circumstances surrounding the statements to determine whether a young
child’s statements were made for medical diagnosis or treatment. Id. In doing so, the court
recognized that the district court “may consider any factors which bear upon the likelihood that
the child made the statement for [a medical diagnosis or treatment] purpose.” Id. A non-
exclusive list of the guiding factors would include:
         The child’s age; whether the child understands the role of the physician in
         general; whether the child was suffering pain or distress at the time; whether the
         child’s statements were inappropriately influenced by others, as by leading
         questions from the physician or a previous suggestive interrogation by another
         adult; whether the examination occurred during the course of a custody battle or
         other family dispute; the child’s ability and willingness to communicate freely
         with the physician; the child’s ability to differentiate between truth and fantasy in
         the examination itself and in other contexts; whether the examination was
         initiated by an attorney (which would suggest that its purpose was for litigation
         rather than treatment); and the timing of the examination in relation to the trial.
Id. The court then held so long as there is little reason to doubt the child’s motivation, district
courts may infer the criteria of I.R.E. 803(4) are satisfied. Id.
        Applying these Kay factors, the Court of Appeals found the medical examinations were
not associated with any domestic dispute, there was no motivation for any of the involved adults
to try to influence the child’s story, the child readily answered questions, the physicians used
simple, open-ended, non-leading questions when speaking with the child, both examinations

                                                   5
occurred shortly after the misconduct occurred, and both examinations were performed at the
hospital where even the young child would realize health was the focus. Id. Thus, the court
ultimately held the district court’s admission of the four-year-old’s statements under I.R.E.
803(4) was not an abuse of discretion because the child made the statements for the purpose of
seeking medical diagnosis or treatment. Id.
        In State v. Nelson, 131 Idaho 210, 953 P.2d 650 (Ct. App. 1998), the Court of Appeals
again held a child’s statements made to a medical professional were made for the purpose of
medical diagnosis or treatment. 131 Idaho at 216, 953 P.2d at 656. In Nelson, the court held that
a ten-year-old’s statements to an emergency room physician about the events leading to the
sexual assault and particulars of the molestation were admissible under I.R.E. 803(4). Id. at 215,
953 P.2d at 655. The court explained there was no basis in the record to infer that the child
believed she was seeing the doctor for any reason other than diagnosis and treatment. Id.
Specifically, the court relied on the facts that the child was taken to the emergency room within
an hour of the sexual assault, the child had told other adults the defendant had hurt her, and the
child complained about pain in sensitive areas. Id.
        For purposes of this appeal it is important to note that Christensen focuses on whether the
victims knew that their statements, made during their interviews and prior to physical
examination, were for medical or diagnostic purposes. Christensen avoids the duty to analyze
these questions under a totality of the circumstances and myopically focuses on only one of the
several Kay criteria listed above. In reviewing the totality of the circumstances before the district
court   we   emphasize     that   the   judge   “has broad discretion in    deciding   whether     to
admit hearsay evidence under one of the exceptions, and this Court will not overturn an exercise
of that discretion absent a clear showing of abuse.” Stanfield, 158 Idaho at 331, 347 P.3d at179.
        The record establishes that the trial court “(1) correctly perceived the issue as one of
discretion; (2) acted within the outer boundaries of its discretion; (3) acted consistently with the
legal standards applicable to the specific choices available to it; and (4) reached its decision by
the exercise of reason.” Lunneborg, 163 Idaho at 863, 421 P.3d at 194. The district court met all
of these factors, and most-importantly for the issue raised on this appeal, it acted consistently
with the proper legal standard as required by Kay and found little reason to doubt the statements
made by A.M.O. and A.G.O. in their respective CARES interviews were made for any reason
other than medical treatment or diagnosis.
                                                 6
        The district court found that CARES’ focus is mainly on medical procedures intended to
discover trauma inflicted on children, to address that trauma, and to treat it. This focus was
relayed to A.M.O. and A.G.O. when Foster explained it was her job to keep their bodies safe and
healthy and that they would see a doctor after the interview was completed. As in Kay, the
district court also found the statements were elicited by non-leading questions as evidenced by
the use of the NICHD protocols. As noted by the court’s analysis in Kay, the State need not show
the child understands the need to speak truthfully to physicians for I.R.E. 803(4) to apply. 129
Idaho at 518, 927 P.2d at 908. “Proof of such an awareness is not required as a matter of
foundation when the declarant is an adult, and in our view it is inappropriate to impose a
differing foundational rule where the declarant is of tender years.” Id. Here, the district court
found little reason from the record to doubt that the statements made by A.M.O. and A.G.O. fell
within the exception for medical diagnosis or treatment. We agree.
        Even more, independently applying the factors listed in Kay also supports admissibility
of the statements made by the twins during their CARES interviews. First, A.M.O. and A.G.O.
were thirteen at the time of the interviews, but they were functioning at the level of a third
grader. 1 Children of thirteen or six, or even as young as four, are capable of making statements
for the purpose of medical diagnosis or treatment. Nelson, 131 Idaho at 216, 953 P.2d at 656;
Kay, 129 Idaho at 518, 927 P.2d 897 at 908. Second, Foster explained the medical purpose of the
interviews to A.M.O. and A.G.O., explaining that it was her job to keep them healthy and safe
and explained they would be seen by a nurse or doctor after the interview. Even more, both
A.M.O. and A.G.O. discussed pain they incurred during the incidents and vaginal bleeding that
occurred after. These facts show A.M.O. and A.G.O. knew their statements were for the purpose
of medical diagnosis or treatment because the statements themselves show they were aware of
the medical staff and why the medical staff was involved. In addition, they freely communicated
with the staff about physical pain and discomfort they experienced from the abuse. Third, the
statements made by A.M.O. and A.G.O. were not inappropriately influenced by others. The
twins had not been interrogated by law enforcement, had minimal investigation from school
officials, and Foster used non-leading questions. Fourth, the interviews did not occur during a


1
  A.M.O. and A.G.O. were both born with chromosome deletion which affects their learning abilities. At the time of
the alleged misconduct, A.M.O. and A.G.O. were thirteen-years-old and in the ninth grade but were functioning at a
third grade level.
                                                        7
custody battle or other family dispute. Fifth, A.M.O. and A.G.O. both communicated freely with
Foster and acknowledged they understood the difference between truth and falsity. Sixth, the
interviews took place before trial.
       Finally, and most importantly, even though CARES interviews serve a dual medical and
forensic purpose, A.M.O. and A.G.O.’s statements were admissible because their statements
remain inherently reliable; they are gleaned from a process designed to aid and inform treatment
and diagnosis of the child’s medical condition. In these circumstances, the child would “still
have the requisite motive for providing the type of ‘sincere and reliable’ information that
is important to that [medical] diagnosis and treatment.” Webster v. State, 827 A.2d 910, 920
(Md. Ct. App. 2003).
       Under these circumstances, the questions and their answers were designed to assist in
proper medical diagnosis or treatment of A.M.O. and A.G.O.’s medical conditions. Dr. Cox, the
medical doctor who testified before the district court about the purpose of CARES interviews,
noted that the forensic interview helps undergird the medical examination. The medical doctor
observes the forensic interview before performing the medical examination so that he or she can
be informed of critical material disclosed during the interview. Dr. Cox testified that after the
forensic interview and psychosocial assessments are completed, a full head-to-toe medical
examination is performed which is often directed by the information learned from the history
collected in those initial interviews. Dr. Cox testified that the forensic interview
       helps in first determining kind of what problems the child may have, what areas [a
       doctor] need[s] to focus [the] assessment on examination-wise. It give[s] [the
       doctor] clues about any physical symptoms the child may have had that may be
       something that needs to be evaluated further like bleeding or pain or discharge or
       other issues. It gives an idea of risk for infections.
Dr. Cox then testified that disclosures by A.G.O. in her forensic interview directly influenced his
examination of her. Additionally, although Dr. Cox did not perform the medical examination on
A.M.O., Dr. Cox testified that the assessment and examination process is standardized and that
each examiner takes the same approach, using communication from the interview to inform the
nature and scope of the medical examination. Thus, the same rationale applies to A.M.O.’s
statements.
       These factors, taken together, establish that the district court did not abuse its discretion
in concluding that A.M.O. and A.G.O. made their statements for the purpose of medical

                                                  8
diagnosis or treatment. While there is also a “forensic” component to the interviews, that concern
is overcome by the medical characteristic of such interviews. See State v. Vigil, 810 N.W.2d 687,
695 (Neb. 2012) (“[A] statement is generally considered admissible under the medical purpose
hearsay exception if gathered for dual medical and investigatory purposes.”); see also Webster,
827 A.2d at 921 (collecting several cases that approve the admission of hearsay statements by a
sexual assault victim given during a forensic interview due to the dual medical and forensic
purposes for the examination).
       In addition, the concern regarding the dual purpose of such interviews is allayed in two
ways. First, the forensic nature of the interview is not primarily designed to gather evidence,
though that is one of its byproducts; it is to help inform the medical process that takes place with
the child throughout their experience at CARES. The interview assists and enlightens, as Foster
testified, as part of the process in helping children keep their bodies safe and healthy,
incorporating seeing a doctor after the interview is completed. Second, as explained below, the
interviews are “forensic” in nature because they are conducted under detailed guidelines
designed, insofar as possible, to obtain untainted information from the child, rather than from the
interviewer through leading questions.
       Thus, the “forensic” moniker given to these interviews does not supplant the prevailing
medical underpinning which supports their admission under Rule 803(4). Stated another way,
while there is clearly a dual purpose to CARES interviews, to both gather information and
inform medical treatment, the information-gathering purpose does not override the medical
necessity of such interviews. As a result, the district court did not abuse its discretion by
admitting the CARES interviews under I.R.E. 803(4).
B.     The district court did not abuse its discretion by admitting the CARES interviews
       without first redacting statements given by A.M.O. and A.G.O. to introductory
       questions, questions designed to build trust and rapport, and questions designed to
       test episodic memory.
       Christensen argues the district court abused its discretion by admitting the CARES
interviews in their entirety without first determining whether particular statements were
admissible under I.R.E. 803(4). Christensen acknowledged that the CARES interviews adhered
to NICHD protocol which has four phases: (1) introductory questions; (2) questions designed to
build trust and rapport; (3) questions designed to test episodic memory; and (4) substantive
questions designed to illicit disclosure that may aid in medical diagnosis or treatment.

                                                 9
Christensen maintains statements elicited from A.M.O. and A.G.O. during the first three phases
of the CARES interviews should have been redacted because those statements were not pertinent
to medical diagnosis or treatment.
       The State argues Christensen failed to preserve this issue below. But even if the issue
were preserved, the State maintains the district court did not abuse its discretion because the
statements elicited in the first three phases of the interview were not hearsay and the statements
were pertinent to medical diagnosis or treatment. Lastly, the State argues if the district court
abused its discretion by admitting the CARES interviews without redaction, the error was
harmless because the statements elicited by A.M.O. and A.G.O. were both tested by cross-
examination and thus any error in admitting the interviews did not contribute to the jury’s
verdict.
   1. Whether the CARES interviews should have been redacted below was adequately
      preserved.
       “For an objection to be preserved for appellate review, ‘either the specific ground for the
objection must be clearly stated, or the basis of the objection must be apparent from the context.’
” Hansen v. Roberts, 154 Idaho 469, 473, 299 P.3d 781, 785 (2013) (quoting Slack v. Kelleher,
140 Idaho 916, 921, 104 P.3d 958, 963 (2004)). Below, Christensen made a general objection to
the admission of the CARES interviews under I.R.E. 803(4). In response to the State’s notice of
intent to use the CARES interviews, Christensen argued “any conversation for the purpose of
building trust or establishing rapport is not relevant to or for the purpose of medical treatment”
and thus should be excluded. Christensen then stated the specific grounds for the objection,
I.R.E. 803(4). It was apparent from the context that Christensen was objecting to the admission
of parts of the interview intended to build rapport and establish trust between the CARES
interviewer and the child. Thus, we hold the issue was adequately preserved.
   2. The district court did not abuse its discretion by admitting the unredacted CARES
      interviews because the statements were not hearsay, or even if they were, Christensen
      failed to particularize his objection regarding the offending statements.
       The statements elicited by the CARES interviewer during the first three components of
the interviews were directed at (1) introductory questions directed at whether the child was
competent to testify; (2) questions designed to build rapport and eliciting information about what
the child likes to do; and (3) probing episodic memory, where the forensic interviewer identified
a recent event and then asked questions designed to elicit details about that event. The questions

                                                10
included what the twins like to do for fun, and whether they understood the importance of telling
the truth. While such answers were made out of court, they were not admitted for the “truth of
the matter asserted.” I.R.E. 801(c). Hearsay is “a statement, other than one made by the declarant
while testifying at the trial or hearing, offered in evidence to prove the truth of the matter
asserted.” Hill, 161 Idaho at 448, 387 P.3d at 116 (emphasis added). The State had no interest in
establishing that A.M.O. likes drawing or swimming. The statements were admitted so that the
jury had the full context of the twins’ statements about the abuse committed by Christensen and
not to establish any disputed facts. Thus, such statements are not hearsay and Christensen’s
objection on that basis is erroneous. See State v. Siegel, 137 Idaho 538, 540–41, 50 P.3d 1033,
1035–36 (Ct. App. 2002) (citing United States v. Gutierrez–Chavez, 842 F.2d 77, 81 (5th Cir.
1988) (“[S]tatements offered only to provide context to a defendant’s admissions are not
hearsay.”). Such statements made during a conversation are admissible to provide background
and “for the limited purpose of putting the responses of the [child] in context and making them
‘intelligible to the jury. . . .’ ” Id. at 541, 50 P.3d at 1036. Thus, such questions help inform the
jury as to the nature, circumstances and “feel” of the interview in context. Simply revealing to
the jury the victim’s statements about what Christensen did to them without more, as Christensen
advocates, would make it difficult for the jury to properly weigh that evidence. As a result, we
hold the district court did not abuse its discretion by admitting the unredacted CARES
interviews.
       Christensen also made no attempt to object specifically to those portions of the interviews
that he wished to have redacted. Perhaps some statements made in the interviews were irrelevant,
or could arguably be hearsay. Even so, without a specific objection to the allegedly inadmissible
portions of the interview, we are left only to surmise what might or might not amount to
offending statements. A general objection to such interviews, without specifics as to which
statements were inadmissible and why, is insufficient to preserve the error for appeal. I.R.E.
103(a)(1)(B). Thus, Christensen’s attempt to assail this portion of the interviews on appeal fails.

                                         VI. CONCLUSION
       The district court did not abuse its discretion by admitting the CARES interviews under
I.R.E. 803(4). Additionally, admission of the CARES interviews without redaction was not an
abuse of discretion. We affirm.
       Chief Justice BURDICK, Justices BRODY, STEGNER and MOELLER, CONCUR.
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