U.S. Department of Justice Office on Violence Against Women (2013). A national protocol for sexual assault  medical forensic examinations adults/adolescents (2ndEd.).    https://www.ncjrs.gov/pdffiles1/ovw/241903.pdf

 

What does the forensic medical examination include?

 

Specifically, the forensic medical exam includes:

• Support and crisis intervention;

• Information gathering from the victim for the forensic medical history;

• An examination/medical assessment;

• Coordination of treatment of injuries;

• Documentation of biological and physical findings;

• Collection of evidence from the victim’s body;

• Information, treatment and/or referrals for sexually transmitted infections, pregnancy and other non-acute medical concerns; and

• Follow-up care as needed to facilitate additional healing, treatment or collection of evidence.

 

Exam Process Components

 

Initial contact

 

• Assess and address emergency medical assistance, safety and support needs of the victim

• Explain to the victim the importance of medical care and evidence collection;

• Coordinate transportation for the victim to the medical facility

• Explain to the victim how to preserve bodily evidence until it can be collected at the exam facility (e.g., do not wash, change clothes, urinate, defecate, smoke, drink, eat, brush hair or teeth, or rinse mouth)

• Explaining in the case of a suspected drug/alcohol facilitated sexual assault, that if the victim cannot wait to urinate until arrival at the medical facility, she should collect/bring a sample to the facility (the sooner a urine specimen is obtained after the assault, the greater the chances of detecting substances that are quickly eliminated from the body

• Explaining to the victim that clothing may be taken as evidence—she may wish to arrange to have a change of clothes at the medical facility. (In some facilities replacement clothing may be available.)

 

Triage and intake

 

Health care providers do the following:

 

• Give sexual assault cases priority medical care;

• Respond to acute injury, trauma care and safety needs before evidence is collected;

• With victim consent, alert other responders of the need for their services—

o An examiner to conduct the forensic medical exam;

o An advocate to provide support, crisis intervention and advocacy;

o A law enforcement officer to take a report, offer protection and begin the investigation;

 

Forensic medical history

 

The examiner seeks the following information:

 

• Date and time of the assault/examination;

• Offender information (if known);

• Assault-related history, including possible involvement of drugs/alcohol;

• Post-assault activities of the victim;

• Pertinent medical history, including, for women, contraceptive/menstruation informationand gynecological history; and

• Recent consensual sexual activity.

 

The examination

 

The examiner does the following:

 

• Conducts the general physical exam;

• Conducts the anogenital exam; and

• Documents findings using written notes, anatomical drawings and/or photography as appropriate.

 

Evidence collection

 

The examiner collects the following:

 

• Clothing evidence;

• Debris (e.g., dirt, leaves, fibers, hair, fingernail swabs);

• Foreign materials and swabs (e.g., bite marks) from the surface of the body;

• Hair combings;

• Hair reference samples as needed;

• Oral and anogenital swabs and smears;

• Known blood or saliva sample or buccal swab for DNA analysis and comparison;

• Toxicology samples as needed; and

• Documentation of evidence as needed.

 

Related medical concerns

 

While the risk of pregnancy, sexually transmitted infection and HIV/AIDs from a sexual assault is low, these are major concerns for victims.

 

The examiner does the following, as relevant to the victim’s age and gender:

 

• Informs the victim of the risk of pregnancy and sexually transmitted infections, testing for HIV/AIDs, and prophylactic steps to avoid pregnancy and infection;

• Provides testing/prophylactic care as needed; and

• Provides referrals for related follow-up health services.

 

Discharge and follow-up instructions

 

The examiner does the following:

 

• Provides the victim with the opportunity/supplies to wash, change clothes (providing replacement clothing if necessary) and get food/beverages;

• Informs the victim about post-exam care (information may include referrals to address health needs related to the assault, discharge instructions, follow-up appointments with the examiner or other health providers, and contact procedures for medical follow-up and documentation of developing/healing injuries and resolution of healing); and

• Coordinates with advocates, law enforcement and other involved professionals to discuss other issues with the victim, including safety planning, comfort needs, informational needs, the investigative process, advocacy and counseling options and follow-up contact procedures.

 

 

What can responders do to make the exam process more comfortable for persons with disabilities?

 

• Understand that victims may have physical, sensory, cognitive, developmental or mental health disabilities or multiple disabilities. Make every effort to recognize issues that could potentially arise during the exam process for victims with disabilities (both in general and in relation to their specific disability) and provide reasonable accommodations upon request.

 

• Be aware that the risk of criminal victimization, including sexual assault, for people with disabilities is much higher than for people without disabilities. People with disabilities are often victimized repeatedly by the same offender. Caretakers, family members or acquaintances may be responsible for the sexual assault. In such a case, the offender may be the person transporting the victim to the medical facility. Jurisdictional and medical facilities’ policies should be in place to provide guidance on how staff should screen for and handle situations that are potentially threatening to patients or facility personnel.

 

• Speak directly to victims, even when interpreters, intermediaries or guardians are present.

 

• Respect victims’ wishes to have or not have caregivers, family members or friends present during the exam. Although these individuals may be accustomed to speaking on behalf of  persons with disabilities, it is critical that they do not influence victims’ statements during the exam process. If aid is required (e.g., from interpreters), do so only with the victims’ consent. Keep in mind that the inability to consent could be temporary (e.g., due to substance use, a psychotic episode or onset of an illness such as high fever or a stroke) and victims may at some point be able to make their own decisions. Again, note that guardians could be offenders—if sexual violence by a guardian is suspected, protective services needs to be contacted.

 

• Assess victims’ needs for assistance during the exam process. Explain the exam procedures to victims and ask what accommodations they require, if any (e.g., people with certain physical disabilities may need help to get on and off the exam table, may need to be positioned differently for the exam, or may need an alternative to the exam table entirely).

 

Do not assume, however, that they will need special assistance. Also, ask for permission before proceeding to help them (or touch them or their service animals or handle their mobility or communication devices).

 

• Ask victims to specify their preferred method of communication. Do not make assumptions. Preferences and capacity can vary widely. For example, not all individuals who are deaf or hard-of-hearing understand sign language or can read lips. Not all blind persons can read Braille. Communication equipment that may be beneficial to victims with sensory and communication disabilities include TTY machines, word boards, speech synthesizers, anatomically correct dolls, materials in alternate formats and access to interpreter services. Responders should familiarize themselves with the basics of communicating with individuals using such devices. Some victims with communication disabilities may prefer communicating through an intermediary who is familiar with their speech patterns.

 

• Recognize that individuals may have some type of cognitive disability (for example, an intellectual disability, traumatic brain injury, neurodegenerative condition such as Alzheimer’s disease, or stroke). Speak to these individuals in a clear and calm voice and ask very specific and concrete questions. Be exact when explaining what will happen during the exam process and why. Be aware that some victims with cognitive disabilities may be easily distracted and have difficulty focusing. To reduce distractions, conduct the exam in an area that has no bright lights or loud noises. It may also be helpful if examiners and others present in the exam room refrain from wearing jewelry or uniforms with ornamental designs.

 

• Recognize that in cases where victims cannot verbalize what happened to them during the assault, evidence collected during the forensic medical exam may be especially crucial to the investigation.

 

• Keep in mind that victims with disabilities may be reluctant to report the crime or consent to the examination for a variety of reasons, including fear of not being believed, fear of getting in trouble and fear of losing their independence. For example, they may need extended treatment for their injuries. The perpetrator may be their caregiver and the only person they rely on for daily living assistance; reporting the assault may force them into a long-term care facility.

 

• Recognize that it may be the first time victims have an anogenital exam. The procedure should be explained in detail in language they can understand. They may have limited knowledge of reproductive health issues and not be able to describe what happened to them during the sexual assault. They may not know how they feel about the incident or even identify that a crime was committed against them.

 

• Some victims with disabilities may want to talk about their perceptions of the role their disability might have played in making them vulnerable to an assault. Listen to their concerns and what the experience was like for them. Assure them that the assault was not their fault. If needed, encourage discussion in a counseling setting on this issue, as well as on what might help them feel safer in the future.

 

• Recognize that the examination may take longer to perform with victims with certain types of disabilities. Examiners should avoid rushing through the examination—such action not only may distress victims, it can lead to missed evidence and information.

 

 

U.S. Department of Justice Office on Violence Against Women (2013). A national protocol for sexual assault  medical forensic examinations adults/adolescents (2ndEd.).  https://www.ncjrs.gov/pdffiles1/ovw/241903.pdf