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Second Edition, Volume 1 of 3
Investigation, Diagnosis, and the Multidisciplinary Team
STM Learning, Inc. Leading Publisher of Scientific, Technical, and Medical Educational Resources Saint Louis www.stmlearning.com Our Mission
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Investigation, Diagnosis, and the Multidisciplinary Team
Angelo P. Giardino, MD, PhD Mary J. Spencer, MD, FAAP Michael L. Weaver, MD, FACEP, CDM Professor and Section Chief Clinical Professor of Pediatrics Medical Director, Clinical Forensic Core Academic General Pediatrics University of California, San Diego School Program Baylor College of Medicine of Medicine Emergency Medicine Senior Vice President/Chief Medical Director Saint Luke’s Health System Quality Officer Child Abuse Prevention and SART Kansas City, Missouri Texas Children’s Hospital Palomar Pomerado Health Houston, Texas San Diego, California Patricia M. Speck, DNSc, APN, FNP-BC, DF-IAFN, FAAFS, FAAN Diana K. Faugno, MSN, RN, CPN, Associate Professor SANE-A, SANE-P, FAAFS, DF-IAFN University of Alabama at Birmingham Forensic Nurse Examiner School of Nursing Barbara Sinatra Children’s Hospital Program Director for Global Affairs Eisenhower Medical Center Department of Family, Community, Emergency Room & Health Systems Rancho Mirage, California Birmingham, Alabama
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Names: Giardino, Angelo P., editor. | Faugno, Diana K., 1950- editor. | Spencer, Mary J., 1936- editor. | Weaver, Michael L., editor. | Speck, Patricia M., 1948- editor. Title: Sexual assault victimization across the life span / [edited by] Angelo P. Giardino, Diana K. Faugno, Mary J. Spencer, Michael L. Weaver, Patricia M. Speck. Other titles: Sexual assault victimization across the life span (Giardino) Description: Second edition. | Saint Louis : STM Learning, Inc., [2017] | Includes bibliographical references and index. Identifiers: LCCN 2016031400 (print) | LCCN 2016032157 (ebook) | ISBN 9781936590018 (v. 1 : alk. paper) | ISBN 9781936590025 (v. 2 : alk. paper) | ISBN 9781936590032 (v. 3 : alk. paper) | ISBN 9781936590476 (v. 1) | ISBN 9781936590568 (v. 2) | ISBN 9781936590575 ( v. 3) Subjects: | MESH: Sex Offenses | Crime Victims | Forensic Medicine | Clinical Medicine Classification: LCC RC560.S44 (print) | LCC RC560.S44 (ebook) | NLM W 795 | DDC 616.85/83--dc23 LC record available at https://lccn.loc.gov/2016031400 Contributors
Philip Beh, MBBS, DMJ, FHKAM, FFFLM Kim Day, RN, SANE-A, SANE-P Associate Professor SAFE Technical Assistance Project Director Department of Pathology International Association of Forensic Nurses The University of Hong Kong Elkridge, Maryland Hong Kong SAR, China Robert B.J. Dorion, BSc, DDS, FACD, D-ABFO David M. Benjamin, PhD Director of Forensic Dentistry Adjunct Associate Professor Laboratoire de Sciences Judiciaires et de Médecine Légale Northeastern University School of Pharmacy Ministry of Public Security for the Province of Quebec Boston, MA Montreal, Quebec, Canada Clinical Pharmacologist and Forensic Toxicologist Chestnut Hill, Massachusetts Sheila D. Early, RN, BScN Coordinator Forensic Health Sciences Option Farah W. Brink, MD Forensic Science and Technology The Center for Family Safety and Healing British Columbia Institute of Technology Nationwide Children’s Hospital Burnaby, British Columbia, Canada The Ohio State University College of Medicine Columbus, Ohio Diana K. Faugno, MSN, RN, CPN, SANE-A, SANE-P, FAAFS, DF-IAFN Nancy B. Cabelus, DNP, AFN-AFN-BC, FAAFS Forensic Nurse Examiner Assistant Professor Barbara Sinatra Children’s Hospital University of Saint Joseph Eisenhower Medical Center West Hartford, Connecticut Emergency Room Detective Rancho Mirage, California Central District Major Crime Squad Connecticut State Police (Ret) Shellee L. Fetters, BSA, RN, CEN, MICN, CFRN Meriden, Connecticut Nurse Consultant Clinical Director Rebecca Campbell, PhD Desert Air Ambulance & Desert Critical Care Transport Professor of Psychology Rancho Mirage, California Department of Psychology Michigan State University Martin A. Finkel, DO, FACOP, FAAP East Lansing, Michigan Professor of Pediatrics, Medical Director Pediatrics Amy Carney, NP, PhD, FAAFS Child Abuse Research Education & Service Institute Board-Certified Nurse Practitioner Rowan University–School of Osteopathic Medicine Associate Professor of Nursing California State University San Marcos Barry A.J. Fisher, MS, MBA San Marcos, California Independent Forensic Science Consultant Crime Laboratory Director (Retired) Colleen Carrell, RN, MSN, CPNP Los Angeles County Sheriff’s Department Nurse Practitioner Indio, California Alice Pediatric Clinic Alice, Texas Teresa M. Garvey, JD Attorney Advisor Susan Chasson, MSN, JD, SANE-A AEquitas Nurse Practitioner Washington, DC Merrill Gappmayer Family Medicine Clinic Provo, Utah Det. Catherine Coleman Johnson (Formerly Kansas City, MO PD) Phillip B. Danielson, PhD Sexual Assault Response Coordinator Professor US Marine Corps Department of Biological Sciences North Carolina University of Denver Denver, Colorado Christine S. Julian, J.D. Assistant Prosecuting Attorney Franklin County Prosecutor’s Office Columbus, Ohio
v Contributors
Viktoria Kristiansson, JD Philip V. Scribano, DO, MSCE Attorney Advisor Director AEquitas Safe Place: Center for Child Protection and Health Washington, DC Division of General Pediatrics The Children’s Hospital of Philadelphia Linda E. Ledray, RN, SANE-A, PhD, LP, FAAN University of Pennsylvania Director SANE-SART Resource Service Professor Minneapolis Medical Research Foundation Clinical Pediatrics SANE-SART Resource Service Department of Pediatrics Minneapolis, Minnesota Perelman School of Medicine at University of Pennsylvania Philadelphia, Pennsylvania Elizabeth A.D. Lee, PhD, APN, ACNS-BC Eleanor Mann School of Nursing Jessica Shaw, PhD University of Arkansas Assistant Professor Fayetteville, Arkansas School of Social Work Boston College Kevin M. Legg, PhD Boston, Massachusetts Research Scientist The Center for Forensic Science Research and Education Patricia M. Speck, DNSc, APN, FNP-BC, DF-IAFN, Willow Grove, Pennsylvania FAAFS, FAAN Associate Professor Jennifer G. Long, MGA, JD University of Alabama at Birmingham Director School of Nursing AEquitas Program Director for Global Affairs Washington, DC Department of Family, Community, & Health Systems Birmingham, Alabama Det. Sgt. (Ret.) Jim Markey, MEd Consultant/Trainer Wendy K. Taylor, PhD, RN, CNS Investigative Lead, LLC Director, Accelerated BSN Program Phoenix Police Department Department of Nursing Fountain Hills, Arizona Mount Saint Mary’s College Los Angeles, California Harry H. Mincer, DDS, PhD Associate Professor Daria Waszak, MSN, RN, CEN Department of Pathology Nursing Instructor College of Medicine Freelance Writer Professor New York, New York Department of Biologic and Diagnostic Sciences College of Dentistry Michael L. Weaver, MD, FACEP, CDM University of Tennessee Health Science Center Medical Director, Clinical Forensic Core Program Memphis, Tennessee Emergency Medicine Saint Luke’s Health System Patricia D. Powers, JD Kansas City, Missouri Senior Deputy Prosecuting Attorney Yakima, Washington Charlene Whitman-Barr, JD Associate Attorney Advisor William J. Reed, MD, FAAP AEquitas Regional Healthcare Center Washington, DC Texas A&M College of Medicine Driscoll Children’s Hospital John F. Wilkinson, JD Corpus Christi, Texas Attorney Advisor AEquitas Rena Rovere, MS, FNP Washington, DC Emergency Medicine Albany Medical Center Albany, New York
vi Foreword to the Second Edition It is well established that sexual assault can have a significant negative and lifelong impact on the physical and emotional well-being of a person. The impact of vic- timization extends far beyond immediate physical or emotional trauma and may cause short- and long-term health consequences, socioeconomic instability, signifi- cant changes to civil or criminal legal outcomes, and psychotherapeutic treatment challenges. Forensically trained professionals, whether they be advocates, nurses, scientists, law- yers, or law enforcement, use their knowledge to break down barriers for victims seeking help following sexual assault. They are more likely to conduct trauma-in- formed investigations; provide enhanced medical examinations; improve the quality of evidence collection and processing; provide comfort, care, advocacy, and other victim services; and participate in sexual assault response teams (SARTs). Knowl- edgeable professionals are more likely to recognize the neurobiology of trauma and how it impacts memory recall abilities and behavior, screen for patterns of abuse or prior assault, test for date rape drugs, offer emergency contraception and preven- tive medications against sexually transmitted infections, and direct survivors to sup- portive services. Quality forensic care fosters a believing atmosphere that supports a survivor’s multifaceted path toward recovery. Sexual Assault Victimization Across the Life Span is the most comprehensive text on its subject to date and truly covers the expansive set of circumstances and complex is- sues that arise with sexual assault. It is filled with useful statistics and provides a solid foundation of knowledge that is translatable to common practice situations. Key terms listed at the beginning of chapters help to inform and provide consistency in language throughout the community. The authors provide expert, multidisciplinary perspectives imperative to creating and sustaining successful SARTs and subsequent- ly paving the way for improved, comprehensive victim experiences. I appreciate the emphasis on complex circumstances, vulnerable populations, and all-too-common scenarios involving college, military, and correctional settings. The usefulness of this text extends beyond a basic understanding of the subject and provides expansive and detailed information for even the most expert reader. I anticipate and look forward to reading and referencing this text many times in the future.
Heather K. DeVore, MD Assistant Professor of Emergency Medicine Georgetown University School of Medicine Executive and Medical Director District of Columbia Forensic Nurse Examiners MedStar Washington Hospital Center Washington, DC
vii Foreword to the Second Edition Sexual assault is a significant public health issue with long-lasting effects on indi- viduals and communities. It is vital that health care professionals have the necessary information and tools to provide the best care to victims of sexual assault. Written by current experts in the field,Sexual Assault Victimization Across the Life Span, Second Edition provides a comprehensive guide to issues of sexual assault. This revised and updated second edition covers current sexual assault issues as well as historical perspectives on services and treatment, and it includes underrepresented populations such as sexually assaulted males, the elderly, rural populations, tribal peoples, and people with physical and developmental disabilities. Even more cutting- edge and current is the inclusion of information on sexual assault in the military and among LGBTQ populations. Some of the highlights from this exemplary new collection follow. In Volume 1 Chapter 3, “Cultural and Linguistic Aspects of Gender-Based Vio- lence Care,” Michael Weaver helps health care providers to acquire or improve their knowledge and skills to provide culturally and linguistically appropriate care to di- verse populations. Of specific focus is helping health care providers to improve com- munication with patients and learn to “convey information in a manner that is easily understood by diverse audiences, including persons of limited English proficiency, those who have low literacy skills or are not literate, individuals with disabilities, and those who are deaf or hard of hearing.” Because it is crucial that health care providers understand informed consent as it relates to victims and perpetrators, Volume 1 Chapter 4, “Informed Consent and Sexual Assault,” succinctly defines and explains the 4 aspects of informed consent and explains the need to understand these aspects as they apply to victim- and pa- tient-centered care. In order to avoid misdiagnosis, it is essential that health care providers be aware of normal and nonspecific findings in children evaluated for sexual abuse. To that end, Farah Brink, Philip Scribano, and Christine Julian clearly explain how to conduct a medical evaluation for suspected child sexual abuse and to avoid misdiagnosis in Volume 1 Chapter 8, “Differential Diagnosis of Child Sexual Abuse.” In order to serve victims more efficiently, health care providers must work coopera- tively with law enforcement, prosecutors, and victim advocates. In Volume 1 Chap- ter 11, “SANE/SART History and Role Development,” Linda Ledray and Patricia Powers provide a history of sexual assault nurse examiner (SANE) and sexual assault response team (SART) programs and instructions to develop and implement SANE/ SART programs. Volume 2 Chapter 4, “Dating Violence in Teens and Young Adults,” gives an ex- cellent overview of adolescent and young adult dating violence and the necessary information that health care professionals need to effectively screen and provide ser- vices for victims of teen dating violence. This chapter also specifically explains the prevalence, consequences, and predictors of teen dating violence and the effect of teen dating violence on physical and mental health. Volume 2 Chapter 5, “Overview of Adolescent and Adult Sexual Assault,”is perhaps the cornerstone of Sexual Assault Across the Life Span. By providing “historical per- spective, epidemiology, and costs to society, components of an effective interdisci- plinary response, the crucial development of sexual assault nurse examiner (SANE) programs, as well as theories behind preventive strategies and promising models,” this chapter offers vital information that ties together overarching subject matter from across the 3-volume set.
ix Foreword to the Second Edition
Sexual assault against men is just beginning to enter the public consciousness, and it continues to be underreported, under-recognized, and undertreated. In Volume 2 Chapter 7, “Adult Male Sexual Assault,” the authors provide a review of recent literature and research on the prevalence of male sexual assault, barriers to reporting, and the effects of sexual assault on the male victims. Most importantly this chapter offers recommendations for “comprehensive and compassionate care and support” of male survivors. Sexual assault of the elderly is believed to be seriously underestimated and underre- ported, and it is neither well understood nor well identified by health care profession- als. Volume 2 Chapter 8, “Sexual Assault Among Older Adults,” will help health care professionals provide informed care to older adult sexual assault victims. In Volume 3 Chapter 3, “Sexual Assault and Abuse in LGBTQ Populations,” the authors provide a brief history of sexual assault and violence in LGBTQ communities as well as a literature review on sexual identities, identification of patterns of sexual assault and violence, and the impact of homophobia and heterosexism on current practices in care of LGBTQ sexual assault victims. The most helpful tool in under- standing these issues is the author’s inclusion of case studies demonstrating cultural considerations for LGBTQ sexual assault victims. Sexual Assault Victimization Across the Life Span is a comprehensive guide for up- to-date and effective response to sexual assault among the diverse populations of an ever-changing society. While written primarily for health care professionals who deal specifically with sexual assault, it will make a vital resource for anyone working with issues related to sexual assault.
Amy Caffrey, MA, LMFT Licensed Marriage & Family Therapist in Private Practice Santa Clara County Domestic Violence Council Commissioner (SCCDVC) SCCDVC Chair of the LGBTQ Domestic Violence/Intimate Partner Violence Committee San Jose State University Part-Time Professor (Psychology Dept) Community Lecturer on Domestic Violence, Sexual Assault and LGBTQ Issues
x Foreword to the First Edition Sexual assault is broadly defined as unwanted sexual contact of any kind. Among the acts included are rape, incest, molestation, fondling or grabbing, and forced viewing of or involvement in pornography. Drug-facilitated behavior was recently added in response to the recognition that pharmacologic agents can be used to make the vic- tim more malleable. When sexual activity occurs between a significantly older person and a child, it is referred to as molestation or child sexual abuse rather than sexual assault. In children, there is often a “grooming” period during which the perpetra- tor gradually escalates sexual contact with the child and often does not use the force implied in the term sexual assault. But it is assault, both physical and emotional, whether the victim is a child, an adolescent, or an adult. The reported statistics are only an estimate of the problem’s scope, with the actual reporting rate being a mere fraction of the true incidence. Surveys of adults show as many as 18% of all women in the United States have been the victim of an attempted or completed rape over the course of their lives. The incidence of male victims is lower because of reluctance of boys and men to report their victimization. The financial costs of sexual assault are enormous. Intangible costs, such as emo- tional suffering and risk of death from being victimized, are beyond measurement. Short term, there are health care consequences, such as unwanted pregnancy, sexu- ally transmitted diseases, serious emotional upheavals, inability to carry out normal daily activities, decreased productivity, and in some cases, loss of life. Long-term disabilities can be both emotional and physical. It is well documented that survivors of sexual abuse have a much higher incidence of serious and chronic mental health problems than control populations of nonabused patients. Posttraumatic stress disor- der, depression, suicidal ideation, and substance abuse are all over-represented among abused groups in cast-control studies. Chronic physical symptoms, such as pain syn- dromes (pelvic, abdominal, chest, myalgias, headaches) and various somatization disorders, are reported in a wide variety of peer-reviewed medical specialty journals. This book is the first to bring together the best information available concerning sexual victimization across the entire life span. Recognizing the radical differences required in approaching child, adolescent, and adult victims, the chapters are orga- nized to present information from the medical and mental health literature specific to various age groups. Victim and perpetrator characteristics are described. Most importantly, those who provide care for these victims and who handle the disposition of the perpetrators are given specific information for all who care for the victims— the crisis hotline staff, law enforcement personnel, prehospital providers, specialized detectives, medical and mental health staff, specialized sexual assault examiners, and counselors. The information is as current, accurate, and specific as it can be in a rapidly evolving field. It will fill a need in many venues where sexual victimization is seen and care is given to victims.
Robert M. Reece, MD Director, MSPCC Institute for Professional Education Clinical Professor of Pediatrics, Tufts University School of Medicine Executive Editor, Quarterly Child Abuse Medical Update
xi Foreword to the First Edition Sexual abuse is not just an epidemic—it is at pandemic proportions. In the United States, perhaps 20% to 25% of adults sustain some form of sexual abuse during their childhood. These numbers are somewhat higher or lower in other countries but certainly do not vary by a factor of even 5. With such a high percentage of the world having been sexually abused, it may be legitimate to ask, is sexual abuse a “normal” behavior? Similarly, what is sexual abuse and why does it exist? Anthropologically, concepts of appropriate sexual behaviors with young humans in- corporate both biologically and culturally derived premises. Biologically, prepubertal animals are not frequent targets for sexual activity. This relative taboo is reasonably ubiquitous across species. Males and females of a given species usually wait until they achieve sexual maturity before they engage in sexual activity. This is utilitarian in that effort is not wasted on a nonreproductive member of the species. Besides olfactory, behavioral, and other cues that the individual is mature (and receptive), there are visual indicators of immaturity that seem to inhibit adults of most species. However, once having achieved sexual maturity an individual is fair game. Through most of human history, this biologic distinction of maturity has also apparently held. When the human life expectancy was a mere 30 years, however, one could not wait until the late teen years to begin reproduction. In more recent historical times (and within certain cultures), a cultural overlay has developed that acknowledges a “delayed” maturity. Thus the age of consent is more likely to be 16 years or so, not age 10 or 11 years when some girls are having their first menstrual period. The concept especially derives from the notion that children need prolonged education and parental nurturance before they should have to compete with the adult population and its risks. The adult is supposed to ignore the develop- ment of secondary sexual characteristics (biologic maturity) and focus on chronologi- cal age with a somewhat arbitrary cutoff (eg, what is the difference between a 15 year old and a 16 year old?). Both the biologic cutoff and the chronological cutoff are respected by most adults in society. Yet some overlook the cultural cutoff and some even ignore the biologic cutoff (ie, have sex with young children). For the latter, this is a violation of both cultural and biologic taboos. Another biology-related taboo is having sex with close kin. The genetic implications could not have been consciously appreciated by humans through most of history, nor by some species, which also abide by this taboo. Yet nearly all human cultures respect the incest taboo—a sign of a relative biologic underpinning for this behavior. Nevertheless, some adult humans also fail to respect this distinction and commit what we consider incest. Views about appropriate and inappropriate sexual activity with younger humans have been codified into law and society as sexual abuse crimes. These are crimes about sex and reflect the perpetrator’s sexual drive. While sexual drives help to main- tain the species and are overall a necessary biologic imperative, sexual abuse incorpo- rates biologically useless activity (ie, sex with biologically immature children) and/or activity that is culturally shunned. In some instances the perpetrator may “love” the child and perhaps be the better caregiver. Yet the violation of taboos elicits a strong reaction by most members of society—reflecting a lack of concern for the child’s well-being and trampling of the society’s biologic and cultural ideations. What can be done about this? One option would be to ignore the abuse. Yet this historically has not been done if the act becomes known, and it fails to meet the developmental needs of children. Another option would be to mount an aggressive prevention campaign aimed at perpetrators before they commit sexual abuse (pri-
xiii Foreword to the First Edition
mary and secondary prevention). This has not been done to any significant extent as yet. The third option is what most of this book is about—identifying sexual abuse when it has occurred and providing the types of interventions that might minimize its impact. We can treat the child and treat and/or incarcerate the offender. Considerable progress has occurred in the last three decades that enables us to better understand, identify and intervene with child sexual abuse. The results of this progress are re- flected in the state-of-the-art descriptions within this volume. These approaches make a real difference in children’s lives and help us to respect the boundaries we place on sexual activity with our young. One unanswered question remains: When will we as a society care enough about our children to make the substantial efforts required to implement the very best in primary, secondary, and tertiary prevention for our children? Until this becomes a cultural imperative of its own, we will continue to need books such as these, and the misery of lost childhoods will contribute to a sordid reality. Let us hope that some future generation can appreciate the brilliance of the work portrayed herein, but is also able to view child sexual abuse as an extinct historical oddity.
Randell Alexander, MD, PhD, FAAP Professor of Pediatrics and Chief Division of Child Protection and Forensic Pediatrics Department of Pediatrics University of Florida Jacksonville, Florida
xiv Preface to the Second Edition It is incumbent upon those responsible for survivors’ well-being to continually inter- rogate and reevaluate best practices in investigation, prosecution, medical care, and prevention of sexual violence. To that end, we offer the revised and updated second edition of Sexual Assault Victimization Across the Life Span. This latest edition is re- conceived as a 3-volume set, lending focus to 3 overarching subjects: the role of the multidisciplinary team, response to specific age groups, and the unique concerns of special survivor populations. Volume 1: Investigation, Diagnosis, and the Multidisciplinary Team details principles of investigation in sexual assault and the responsibilities of multidisciplinary team members across fields, including medicine, medical forensic examination, emer- gency medical services, law enforcement, prosecution, and victim advocacy. It is of vital importance that readers in every branch of the multidisciplinary team recall the essential value of interdisciplinary cooperation in the interest of resilient recovery for those in our care. Volume 2: Evaluation of Children and Adults and Volume 3: Special Settings and Sur- vivor Populations outline response strategies tailored to the needs of specific survivor groups. The second volume addresses sexual assault and abuse in survivors across the life span, including chapters on teen dating violence, campus sexual assault, sexual abuse of the elderly, STIs in children, and sexually assaulted adolescent males. The third volume examines the role of environment and survivor identity in cases of sexual assault. Readers will enjoy the benefit of chapters geared toward sexual assault survivors in the military, correctional settings, LGBTQ communities, and others. We are pleased to offer the new and expanded second edition of Sexual Assault Vic- timization Across the Life Span to our readers and colleagues. We sincerely hope and believe that its contents and the collective expertise of its contributors will prove valuable in research, response, and care for survivors of sexual violence.
Angelo P. Giardino, MD, PhD Diana K. Faugno, MSN, RN, CPN, SANE-A, SANE-P, FAAFS, DF-IAFN Mary J. Spencer, MD, FAAP Michael L. Weaver, MD, FACEP, CDM Patricia M. Speck, DNSc, APN, FNP-BC, DF-IAFN, FAAFS, FAAN
xv Preface to the First Edition What is sexual assault? It is a crime of violence, where the assailant uses sexual con- tact as a weapon, seeking to gain power and control. Often youths and adolescents are disproportionately targeted, although sexual assault can occur at any age. Sexual assault is also an act of opportunity. Particularly vulnerable populations include chil- dren, especially young females, and individuals who are less able to care for them- selves, such as the homeless or physically or mentally handicapped persons. Their vulnerability and ease of manipulation makes them prey. Who commits these acts? While there is no classic profile of an offender, child sex abusers tend to be males who are known to the child’s caregivers, and 80% of the women who are assaulted know their attackers, as well—they are their ex-husbands, their stepfathers, their boyfriends, and other friends or relatives. Men may also ex- perience victimization. To protect victims from these offenders will require a change in the attitude of soci- ety toward its most vulnerable members. Society must value these individuals before anything will be done. Education plays a key role in accomplishing this change in attitude. This book was prepared with the goal of disseminating the information required to bring about change, to better protect and care for victims of sexual as- sault. Written for health care professionals and other mandated reporters, Sexual Assault Victimization Across the Life Span offers a complete approach to the topic. The problem is defined, all aspects are explored, and treatment and interventions are outlined. Victim characteristics are explored, especially those seen in children. But most importantly, useful information is offered to those who provide care for these victims and those who handle the disposition of the perpetrators. We see the problem through the eyes of many professionals: physicians, paramedics, law en- forcement personnel, the judicial system, social workers, and people who work with children. This covers everyone from the crisis hotline staff, to police and law enforce- ment personnel, to prehospital providers, to specially trained detectives, to skilled medical staff, to trained sexual assault examiners, to rape crisis counselors. Finally, the text offers information on programs that are in place or are under consideration to aid in the prevention of sexual assault. Knowledge gives us the power to intervene, and this book offers current, accurate, and specific data concerning the problem of sexual assault. With the information at hand, we can become empowered and participate in effective interventions to prevent sexual assault as well as care for its victims.
Angelo P. Giardino, MD, PhD
xvii Reviews The second edition of Sexual Assault Victimiza- Sexual Assault Victimization Across the Life The new Sexual Assault Victimization Across tion: Across the Life Span is a comprehensive, Span, Second Edition is a comprehensive text the Life Span, Second Edition is a must-have evidence-based collection of resource material for that will be a valuable resource for all health resource for those who care for or respond to the sexual assault nurse examiner (SANE) writ- care providers involved in the evaluation and victims of sexual assault and abuse. There are ten by experts in the field of forensic medicine management of sexual assault victims. The several essential texts that I recommend programs and nursing. Chapters address the holistic health full, 3-volume set consists of 39 chapters, each consider keeping close at hand for reference, and needs of the sexual assault patient. Chapters dealing with a different aspect of sexual assault, this book is one of them. SANE programs and of particular interest for the SANE include including assault of boys and male adolescents, multidisciplinary collaborative team members those addressing the medical forensic exam and persons with disabilities, and assault among should consider this for their professional evidence collection. Several chapters address LGBTQ populations. Chapters are comprehen- bookshelves and libraries. It provides crucial the sensitive needs of special populations such sive and detailed. Of particular value are the information on the range of issues that may have as children, the elderly, victims of gender-based sections referred to as “Tips from the Bench,” potential impact on sexual assault victims of all violence, and male patients. The chapters are that include comments beyond the medical ages. Included in this new edition are critical well written, with attention to detail and cur- assessment that may have relevance to child issues sexual assault examiners and the entire rent research. There are a plethora of case studies protective services, law enforcement, and mental response team can tackle together as they work to and photographs to illustrate the key points in health providers. In addition, each chapter starts provide competent, ethical, patient-focused care. chapters. Each chapter ends with discussion ques- off with a section designated “Purpose of the These issues can impact the long-term health tions, challenging readers to thoughtfully consider Chapter” that sets the agenda for the chapter, and well-being of their patients and ultimately adoption into their practice. These books are a followed by the chapter’s learning objectives. the safety of their communities. must-have for SANEs and SANE programs. This book will serve as an invaluable guide to Kim Day RN, SANE-A, SANE-P Ann Adlington, MS, BSN, RN, SANE-A those who care for sexual assault victims. SAFE Technical Assistance Project Director South Region SANE Coordinator Carol D. Berkowitz, MD, FAAP, FACEP International Association of Forensic Nurses Advocate Health Care Executive Vice Chair Elkridge, Maryland Hazel Crest, Illinois Department of Pediatrics Harbor-UCLA Medical Center Sexual Assault Victimization Across the Life Sexual Assault Victimization Across the Life Distinguished Professor of Pediatrics Span is an intricate and comprehensive com- David Geffen School of Medicine at UCLA Span, Second Edition is an expansive, thorough pendium of information on all aspects of sexual Los Angeles, California 3-volume resource for medical professionals and assault. The breadth and depth of information is multidisciplinary partners working on behalf of exceptional—from detailing the responsibilities Chapter 1, “Overview of Sexual Assault, Abuse, sexual assault victims. Unique to this collection of prosecutors and sexual abuse examiners, to a and Exploitation” is the perfect synopsis of is the focus on evidence-based investigation, discussion of workplace sexual assault, and issues the history of sexual assault and abuse across diagnosis, evaluation, and the needs of special of dealing with sexual abuse in children with dis- the life span. Regardless of their background, populations. One author highlights the complex abilities. This 3-volume compilation should be a multidisciplinary team members can glean need for understanding the cultural background mandatory resource in any organization engaged critical knowledge from the text, which explains and semantic/linguistic nuances essential to a in any facet of sexual assault response or for the history of sexual assault and child protection compassionate approach to sexual assault victims. anyone who wants a resource that deals with any laws in the United States and across the world. Others emphasize the critical importance of a or all of the multiple aspects of sexual abuse. The thoughtful, trauma-informed approach to the The chapter “Sexually Transmitted Infections logical, functional structure of the volumes divid- victim, underscored by a core principle—“Start in Sexually Abused Children” concisely covers ing the subject into investigation, evaluation by believing.”—which may be the key to safe the epidemiology of the major STIs in children, of children and adults, and lastly, a volume on disclosure, participation in a medical forensic testing methods, implications of the results, and special settings and survivor populations greatly evaluation, and cooperation with investiga- treatment options. Diagnosing sexual abuse enhances the ease of using this material. tion and prosecution, all of which enhances the is intrinsically challenging but this chapter Theodore N. Hariton, MD, FACOG likelihood of justice for victims. Each chapter provides an exceptional overview for clinicians, Forensic Obstetrician and Gynecologist includes current foundational information, while citing outstanding references. Diplomate of the American Board of Obstetrics and Gynecology clearly delineated lists of symptoms or sugges- “Screening for and Treatment of Sexual Abuse Fellow of the American College tions, and discussion questions. This should be Histories in Boys and Male Adolescents” a go-to reference for sexual assault response team of Obstetrics and Gynecology provides tools to appropriately care for these Fellow of the American Academy partners in health care, criminal justice, and children. The authors discuss evidence-based victim advocacy. of Forensic Scientists research regarding trends in child sexual abuse Life Fellow of the Los Angeles Obstetrics Eugenia Barr, PhD, LMFT-S and highlight slight but important differences and Gynecology Society Eugenia Barr Counseling and Consulting, LLC between young male and female victims. North American Society of Pediatric Denison, Texas Laurie Charles, MSN, RN, SANE-A, SANE-P and Adolescent Gynecology Clinical Assistant Professor American Professional Society Forensic Health Care on the Abuse of Children Texas A&M College of Nursing American Academy of Forensic Scientists Bryan, Texas Tuscon, Arizona
xix Reviews
Forensic nurses must command knowledge The new second edition of Sexual Assault of many variables, including a wide array of Victimization Across the Life Span is an patient traits, types of physical and emotional important contribution to the field of sexual trauma, and appropriate treatment options. assault and violence. It is probably the leading Sexual Assault Victimization Across the Life textbook in the field, and it is a must-have for Span provides a rare combination of intri- all medical professionals who care for victims of cate procedural detail while maintaining an sexual violence. The beauty of the book is that easy-to-follow tone that is instantly valuable to it truly covers victims across the life span and seasoned practitioners as well as professionals provides guidance and tools to address the needs just gaining familiarity with the complexities of all survivors. The text is logically organized inherent to sexual assault exams. Topics ranging into 3 volumes: Investigation, Diagnosis, and from exam procedures to tips on preparing for the Multidisciplinary Team, Evaluation of testimony in court are readily accessible through Children and Adults, and Special Settings and the quick reference format. The text goes beyond Survivor Populations. Each chapter contains theoretical ideas and definitions, providing key points highlighting important concepts and step-by-step instructions for techniques to iden- principles for the benefit of the reader. tify causality factors and detailed procedures Ralph Riviello, MD, MS, FACEP for delivering appropriate treatment. This is a Professor and Vice Chair of Clinical “one-stop shop” for current best practices that Operations any professional associated with the sexual as- Department of Emergency Medicine sault response community can instantly put into Drexel University practical use. Medical Director Sarah L. Pederson, BSN, RN, SANE-A Philadelphia Sexual Assault Response Center SANE Coordinator Philadelphia, Pennsylvania Rape Crisis Center Marietta, Georgia
xx Contents in Brief
Chapter 1: Health Consequences of Sexual Trauma Across the Life Span ...... 1
Chapter 2: Anogenital Anatomy: Developmental, Normal, Variant, and Healing ...... 53
Chapter 3: Cultural and Linguistic Aspects of Gender-Based Violence ...... 89
Chapter 4: Informed Consent and Sexual Assault ...... 109
Chapter 5: Bite Mark Evidence ...... 121
Chapter 6: Forensic Serology: Current and Emerging Technologies ...... 137
Chapter 7: Evidence Collection From Victims of Sexual Violence ...... 169
Chapter 8: Differential Diagnosis of Child Sexual Abuse . . 201
Chapter 9: Verbal Evidence: Testifying in Court ...... 229
Chapter 10: International Systems Response to Sexual Violence ...... 249
Chapter 11: SANE/SART History and Role Development . . 261
Chapter 12: Evaluating Sexual Assault Nurse Examiner (SANE) Programs: Effectiveness in Multiple Domains . . . . 283
Chapter 13: Sexual Abuse: Understanding the Approach to the Medical Examination of Child and Adolescent Victims . 299
Chapter 14: Forensic Examination of the Sexual Assault Suspect ...... 335
Chapter 15: Role of EMS Prehospital Care Providers . . . . 355
Chapter 16: Law Enforcement Issues ...... 363
Chapter 17: The Role of Police as First Responders . . . . . 377
Chapter 18: Legal Issues in Sexual Assault From a Prosecutor’s Perspective ...... 387
Index ...... 413
xxi STM Learning, Inc.
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Chapter 1: Health Consequences of Sexual Trauma Across the Life Span 1 Purpose of Chapter ...... 1 Objectives 1 Key Points 1 Key Terms 2 History 3 Review of the Literature 8 Physical Health Consequences of Trauma ...... 8 General Health Function 8 Neurologic and Cognitive Function 14 Pain Perception ...... 15 Headaches 15 Musculoskeletal Function ...... 16 Impaired Auditory and Visual Function ...... 16 Gastrointestinal Function 16 Liver Function 17 Urinary Function 17 Endocrine Function 17 Reproductive Function ...... 18 Sexually Transmitted Infections ...... 19 Immune and Hematologic Function ...... 19 Respiratory Function ...... 19 Cardiovascular Function 20 Arrhythmias ...... 20 Premature Mortality 20 Summary and Implications 20 Psychological Consequences of Trauma 21 Emotional Function 21 Anxiety Disorders ...... 21 Posttraumatic Stress Disorder ...... 25 Phobia and Panic Disorders 25 Depression ...... 26 Disassociation 26 Somatization ...... 26 Personality Disorder 27 Schizophrenia and Psychosis ...... 27 Bipolar Disorder 27 Summary and Implications 27 Behavioral Consequences of Trauma 27 Substance Abuse 27 Risky Sexual Behaviors 32 Eating Disorders 32 Sleep Disorders ...... 32
xxiii Contents in Detail
Employment, Financial, and Residential Instability 33 Troubled Relationships ...... 33 Violence ...... 33 Self-Harm and Suicide 33 Summary and Implications 34 The State of the Science 34 Current Promising Practices in Care of Sexual Abuse Victims ...... 34 The Future 37 Research: Prevention ...... 37 Research: Evidence-Based Prevention Activities ...... 38 Research: Impact of SANE/SAFE/SART on Victim and Prosecution ...... 39 Discussion Questions 40 References 40
Chapter 2: Anogenital Anatomy: Developmental, Normal, Variant, and Healing ...... 53 Purpose of Chapter ...... 53 Objectives 53 Key Points 53 Key Terms 54 Medical Embryology and the External Genitalia ...... 55 Development of the External Genitalia in Boys 56 Anatomic Variations in Boys ...... 56 Development of the External Genitalia in Boys 58 Anatomic Variations in Girls ...... 59 Variations of the Internal Genitalia 61 Ovary 61 Uterus 62 The Hymen ...... 62 Variations in Configuration 62 Prevalence in Studies ...... 65 Clinical Features of the “Normal” Hymen ...... 65 Posterior Hymenal Measurement 66 The Transhymenal Diameter ...... 67 Effects of Estrogen at Birth and During Pregnancy 68 Puberty 69 Females ...... 69 Precocious Puberty 70 Thelarche ...... 70 Pubarche and Adrenarche ...... 70 Internal Genitalia ...... 71 Cervix 71 External Genitalia ...... 71 Males 72 Pubertal Variations in Males ...... 73 Sexual Maturity Rating ...... 75 Development of the Anorectum 76 Examination of the Normal Perineum and Anorectum ...... 76 Color Changes 77 Red ...... 77 Brown ...... 77 Blue ...... 77 White 77 Black 77 Anatomical Variations 78 Variations in Anorectal Development 79 xxiv Contents in Detail
Healing Following Genital and Perianal Injuries 79 Discussion Questions 81 References 81 Additional Resources 87
Chapter 3: Cultural and Linguistic Aspects of Gender-Based Violence ...... 89 Purpose of Chapter ...... 89 Objectives 89 Key Points 89 Key Terms 90 Introduction ...... 90 Historic Cultural and Linguistic Developments 91 Evolving Concepts, Terminology, and Definitions ...... 91 Regulatory Impact ...... 92 State Licensure Requirements 92 Professional Guidelines and Standards 92 Considerations Before Conducting the Medical Forensic Examination 93 Developing Medical Forensic Forms and Health Literacy ...... 93 Preparing the Medical Forensic Examination Room 94 Preparing to Provide a Medical Forensic Examination 95 Working With an Interpreter ...... 97 Obtaining the Medical Forensic History 98 Considerations During the Medical Forensic Examination 99 Photographic Imaging During the Medical Forensic Examination ...... 99 Considerations After the Medical Forensic Examination ...... 100 Emergency Contraception ...... 100 Discharge Planning 100 Professional Biases of the Sexual Assault Response and Resource Team ...... 101 Overarching Principles for Cross-Cultural Care 102 Conclusion 103 Discussion Questions 103 Appendix 3-1 104 References 105
Chapter 4: Informed Consent and Sexual Assault 109 Purpose of Chapter ...... 109 Objectives 109 Key Points 109 Key Terms 110 Introduction ...... 111 History 111 Informed Consent in the Sexual Assault Care Setting 111 The Process ...... 112 Medical Forensic Evaluation ...... 112 Benefits of the Medical Forensic Evaluation 112 Risks of Medical Forensic Evaluations 112 Release of Personal Information ...... 113 Photodocumentation ...... 113 Medication 113 Consent 114 Adolescents 114 Children 114 Intellectually and Mentally Impaired Patients 114 Incapacitated Patients 115
xxv Contents in Detail
Unconscious Patient ...... 115 Suspect Examinations 116 Conclusion 116 Discussion Questions 117 References 117
Chapter 5: Bite Mark Evidence 121 Purpose of Chapter ...... 121 Objectives 121 Key Points 121 Key Terms 121 Introduction ...... 122 Bite Mark Recognition ...... 122 Types 122 Classic Presentation 123 Common Presentations and Problems 127 Bite Mark Management 129 Bite Mark Photography 131 Bite Mark Impression 133 Bite Mark Microscopy ...... 134 Comparison 134 Conclusion 135 Discussion Questions 135 References 135
Chapter 6: Forensic Serology: Current and Emerging Technologies ...... 137 Purpose of Chapter ...... 137 Objectives 137 Key Points 137 Key Terms 138 Introduction ...... 139 Sexual Assault and the Locard Principle 140 History and Relevance of Serology in the Age of Deoxyribonucleic Acid ...... 140 Technological Demands and Practitioner Responsibilities 141 General Categories of Serological Testing ...... 142 Chemical Reaction−Based Assays 142 Enzyme Activity−Based Assays 142 Antibody Binding−Based Assays 143 Light/Fluorescence Microscopy−Based Assays 145 Serological Tests for Specific Body Fluids 146 Alternative Light Sources 146 Seminal Fluid and Spermatozoa ...... 147 Saliva ...... 150 Blood 151 Urine and Fecal Matter ...... 152 Vaginal Fluid ...... 153 Scientifically Rigorous Reporting of Serological Test Results 154 Research and Development in Forensic Serology ...... 155 Protein Biomarkers and Mass Spectrometry 155 mRNA and miRNA Biomarkers 160 Epigenetic Markers 161 Raman Spectroscopy ...... 161 Conclusion 162 Discussion Questions 162 References 163 xxvi Contents in Detail
Chapter 7: Evidence Collection From Victims of Sexual Violence 169 Purpose of Chapter ...... 169 Objectives 169 Key Points 169 Key Terms 170 History 170 Sexual Assault Nurse Examiner Programs Introduced in the United States . . . . 172 United States National Protocol 2013 173 Review of the Literature 174 Current Evidence Base ...... 174 Sexual Assault Evidence Collection Kit ...... 174 Consent for Treatment and Evidence Collection 175 Clothing 177 Known Deoxyribonucleic Acid (DNA) Samples 180 Bloodstains 180 Debris and Foreign Materials ...... 180 Fingernail Clippings and Scrapings 181 Known Hair Samples ...... 185 Swabs and Smears ...... 185 Toxicology ...... 187 Collection of Dried Saliva Secretions and Use of the Double-Swab Technique . 187 Dental Floss 188 Alternate Light Sources ...... 188 Evidence Collection and Use of Photography 188 Management and Storage of Evidence 190 Chain of Custody ...... 190 Backlog of Evidence Collection Kits ...... 190 Current Practices in Care of Adult Sexual Assault Victims 192 Reports to Law Enforcement ...... 192 Nonreports to Law Enforcement 192 Anonymous Reports ...... 192 Use of DNA 193 The Future 196 Discussion Questions 196 Appendix 7-1 196 References 199
Chapter 8: Differential Diagnosis of Child Sexual Abuse 201 Purpose of Chapter ...... 201 Objectives 201 Key Points 201 Key Terms 202 Introduction ...... 202 Variations of Normal Anatomy 203 Genital Anatomy 204 Anal Anatomy 208 Nonabusive Trauma ...... 209 Dermatologic Disorders 211 Lichen Sclerosus et Atrophicus 211 Seborrheic Dermatitis 212 Contact Dermatitis 213 Psoriasis ...... 213 Hemangiomas 213 Blistering Disorders 213
xxvii Contents in Detail
Infectious Disorders ...... 214 Vulvovaginitis 214 Group A Streptococcus ...... 215 Human Papillomavirus ...... 215 Genital Ulcerative Lesions ...... 217 Molluscum contagiosum 218 Schistosomiasis ...... 218 Pinworms 219 Vaginal Foreign Body Mimicking Infection 220 Candida albicans 220 Inflammatory Disorders 221 Crohn’s Disease ...... 221 Kawasaki Syndrome 221 Behcet Syndrome 221 Miscellaneous Disorders 221 Idiopathic Calcinosis Cutis 221 Mimics of Bruising 221 Urologic Conditions ...... 221 Rectal Prolapse 222 Hair Tourniquet Syndrome 222 Labial Adhesions 222 Legal Implications of Differential Diagnosis ...... 223 Conclusion 223 Discussion Questions 224 References 224
Chapter 9: Verbal Evidence: Testifying in Court ...... 229 Purpose of Chapter ...... 229 Objectives 229 Key Points 229 Key Terms 230 Introduction ...... 231 Overview of the Court System ...... 231 Participants 231 The Expert Witness 232 The Nurse as Expert Witness 233 Preparing for Trial ...... 234 Trial Proceedings 234 The Deposition 235 Subpoenas ...... 235 Duces Tecum ...... 235 Giving a Deposition 236 Active Listening ...... 236 Identifying Poorly Formed Questions 238 The Goal of Questioning 239 Testing Case Facts and Field Expertise 240 Testing Knowledge Sources 241 After the Deposition ...... 241 Testifying in Court 241 Direct Examination 243 Daubert and Frye ...... 243 Cross-Examination 244 The Goals of Questioning ...... 245 Conclusion 246 Discussion Questions 246 References 246 xxviii Contents in Detail
Chapter 10: International Systems Response to Sexual Violence ...... 249 Purpose of Chapter ...... 249 Objectives 249 Key Points 249 Key Terms 249 Overview 250 Cooperation and Collaboration ...... 250 Public Policy ...... 250 DNA Databases ...... 250 Sexual Violence From a Global Perspective 252 Incidence 252 Consequences 252 Societal Costs ...... 253 Models of Victims’ Services ...... 253 Hospital-based or Hospital-affiliated Services ...... 253 Medicolegal-based Services ...... 253 Advocate- or Community-based Services 254 Current Evidence-based State of the Science 254 Current Promising Practices in the Care of Sexual Assault Victims 255 Challenges 256 Conclusion 257 Discussion Questions 258 Appendix 10-1 ...... 258 References 259
Chapter 11: SANE/SART History and Role Development . . 261 Purpose of Chapter ...... 261 Objectives 261 Key Points 261 Key Terms 263 Introduction ...... 263 History 263 The Need for SANE-SART Programs 263 SANE Program Development 265 What is a SANE? SAFE? FE? 266 SANE Scope of Practice, Education, and Certification ...... 266 Medical Care ...... 266 Reporting 267 Emotional Support and Crisis Intervention 267 How a Model SANE-SART Program Operates 267 Hospital-based SANE Programs ...... 268 Nonmedical Community-based SANE Programs 268 Community SART Response and Responsibilities ...... 269 SANE Responsibilities 269 Non-Report Sexual Assault Examinations 269 Mandatory Reporting ...... 269 When the Patient Does Not Want to Report 270 When a Report Is Made 270 Discharge ...... 270 SANE Training ...... 270 State-Level Certification ...... 270 IAFN Certification 270 SANE Education Components ...... 271 SANE Education Trends 272
xxix Contents in Detail
SART: A Community Approach ...... 272 Who Is a SART? 272 Two SART Models ...... 273 Joint Interview SART Model ...... 273 Joint Interview SART Model Limitations ...... 274 Coordinated SART Model 274 Collaborative SART Model Limitations 275 Evidence of SANE-SART Efficacy 275 Improved Collaboration ...... 275 Higher Reporting Rates ...... 275 Shorter Examination Time ...... 276 Better Forensic Evidence Collection 276 Improved Medical Care ...... 277 Improved Prosecution 277 Conclusion 278 Discussion Questions 278 References 278 Additional Reading/Resources ...... 281
Chapter 12: Evaluating Sexual Assault Nurse Examiner (SANE) Programs: Effectiveness in Multiple Domains 283 Purpose of Chapter ...... 283 Objectives 283 Key Points 283 Key Terms ...... 283 History 284 Care of the Sexual Assault Victim in the Emergency Department Setting . . . . 284 Care of the Sexual Assault Victim by the Sexual Assault Nurse Examiner 285 Review of the Literature 286 Psychological Effectiveness ...... 286 Medical Effectiveness ...... 287 Forensic Effectiveness ...... 288 Legal Effectiveness ...... 289 Community Effectiveness ...... 290 Current Promising Practices in the Care of Sexual Assault Victims 290 Conclusion 291 Discussion Questions 293 References 294
Chapter 13: Sexual Abuse: Understanding the Approach to the Medical Examination of Child and Adolescent Victims . 299 Purpose of Chapter ...... 299 Objectives 299 Key Points 300 Key Terms 300 Purpose of the Medical Examination in Cases of Child Sexual Abuse 300 Preliminaries to Conducting the Medical Examination 301 Preliminary Evaluation: Step One ...... 302 Preliminary Evaluation: Step Two ...... 302 Indications for a Physical Examination ...... 304 Determining Need for an Immediate Examination 305 Deferring the Examination 306 Preparing the Child for a Physical Examination 306 Examination Positions and Techniques ...... 307 Review of Genital and Anal Anatomy ...... 310 xxx Contents in Detail
Vagina 310 Vaginal Vestibule 310 Hymenal Membrane ...... 311 Hymenal Orifice Diameter 312 Anus 314 Anal Anatomy 314 Interpreting Residual Effects From Sexual Contact 316 Examining and Interpreting Anal Findings 317 Male Genitalia 317 Residual Effects From Sexual Contact: Patterns of Trauma 318 Genital Fondling 319 Vulvar Coitus ...... 319 Vaginal Penetration 319 Accidental Injuries 320 Labial Agglutination ...... 320 Extragenital Trauma 321 Sodomy and Genital-to-Anal Contact Without Penetration ...... 321 Interpretation of Healed and Healing Injuries ...... 322 Sexually Transmitted Infections 323 Forensic Evidence ...... 323 Medical Conditions That Mimic Child Sexual Abuse ...... 324 The Medical Record and Diagnostic Conclusions 324 Documenting the Clinical Evaluation 325 The Medical Record: Overview ...... 326 Medical History: Documentation ...... 326 Putting it All Together: Formulating a Diagnosis ...... 327 History of Sexual Abuse Without Diagnostic Evidence ...... 328 Diagnostic Findings Supported by History 328 Diagnostic Findings Without Support of History ...... 328 Confirmed Abuse Without Residual Signs ...... 328 Insufficient History and Diagnostic Findings ...... 329 Other Possible Scenarios 329 Summary of Cases ...... 329 Conclusion 330 Discussion Questions 330 References 330
Chapter 14: Forensic Examination of the Sexual Assault Suspect 335 Purpose of Chapter ...... 335 Objectives 335 Key Points 335 Key Terms 336 Introduction ...... 336 Legal Considerations 337 Components of the Sexual Assault Suspect Evidence Collection Kit ...... 338 Sexual Assault Suspect Forensic Examination Procedure 338 Swab Collection ...... 339 Photographs 339 Clothes Collection ...... 340 General Assessment 340 Alternate Light Source 341 Head Hair Combing and Collection ...... 345 Facial Hair Combing or Swabbing ...... 346 Oral 346
xxxi Contents in Detail
Hands 346 Fingernails ...... 347 Genital Examination ...... 348 Pubic Hair ...... 348 Penile and Scrotal Swabbing ...... 348 Buttock, Perineum, Anal, and Rectal Examination ...... 348 Blood and Urine Samples 350 Conclusion 351 Discussion Questions 351 Appendix 14-1 ...... 351 References 353
Chapter 15: Role of EMS Prehospital Care Providers . . . . 355 Purpose of Chapter ...... 355 Objectives 355 Key Points 355 Key Terms 356 Psychology of Victims ...... 356 Forensic Evidence ...... 357 Preserve Crime Scene Evidence Regarding Clothing ...... 358 Preserve Crime Scene Evidence Regarding Wounds 359 Preserve Crime Scene Evidence Regarding Body Fluids ...... 359 Transporting Victims to Hospitals 360 Discussion Questions 361 References 361 Additional Reading/Resources ...... 362
Chapter 16: Law Enforcement Issues 363 Purpose of Chapter ...... 363 Objectives 363 Key Points 363 Key Terms 364 Introduction ...... 364 Processing the Scene and Collection Evidence ...... 365 The Interview Process ...... 369 Guidance on Interviewing the Victim 371 Search Warrants 372 Corroborating Evidence 373 Social Media and other Evidence Types to Consider ...... 373 One-Party Consent of Controlled Phone Call 373 Other Considerations 374 Conclusion 375 Discussion Questions 375 References 376 Additional Reading/Resources ...... 376
Chapter 17: The Role of Police as First Responders . . . . . 377 Purpose of Chapter ...... 377 Objectives 377 Key Points 378 Key Terms 378 Perpetration for First Responders ...... 379 Victim Contact 379 Trauma and Victim Reactions to a Traumatic Events 381 Offender-Focused Investigations ...... 382 xxxii Contents in Detail
The Forensic Medical Examination ...... 383 Investigative Follow-up and Interviews ...... 383 Criminal Prosecution 384 Ongoing Contact and Victim Support ...... 385 Conclusion 385 Discussion Questions 385 References 386
Chapter 18: Legal Issues in Sexual Assault From a Prosecutor’s Perspective 387 Purpose of Chapter ...... 387 Objectives 387 Key Points 387 Key Terms 388 Introduction ...... 389 A Quick Note on Victim Rights 390 Overview of Sexual Assault Laws Across the United States 390 Unique Dynamics of Sexual Assault ...... 390 Sexual Assault Forensic Exam 392 Investigation ...... 394 Criminal Justice Process 396 Statute of Limitations 397 Charging the Case ...... 397 Preliminary Arraignment 397 Appointment of Counsel 398 Plea Negotiations 398 Probable Cause Determination ...... 399 Probable Cause (Preliminary) Hearing 399 Grand Jury Proceedings ...... 400 Pretrial Motions ...... 400 Rape Shield 400 Other Bad Acts ...... 401 The Trial 401 Jury Selection ...... 401 Expert Witnesses 402 Medical ...... 402 Toxicology ...... 403 Criminalistics 403 Victim Behavior 403 Developmental Disabilities 403 Mental Health 404 Common Defenses 405 Conclusion 405 Discussion Questions 405 References 405 Additional Reading/Resources ...... 410
Index ...... 413
xxxiii Second Edition, Volume 1 of 3
Investigation, Diagnosis, and the Multidisciplinary Team
STM Learning, Inc. Leading Publisher of Scientific, Technical, and Medical Educational Resources Saint Louis www.stmlearning.com
xxxv 1 Chapter
Health Consequences of Sexual Trauma Across the Life span Elizabeth Lee, PhD, APN, ACNS-BC Patricia M Speck, DNSc, APN, FNP-BC, DF-IAFN, FAAFS, FAAN
Purpose of Chapter Sexual trauma experienced in childhood or as an adult has impact beyond temporal bruises, soft tissue injury, or broken bones.1 The wounded psyche, left unhealed, can yield detrimental health consequences throughout life.2 Not all negative health outcomes result from learned self-destructive lifestyle choices of trauma survivors; spontaneous unmitigated and functioning psychological and physical changes, possibly permanent, occur after trauma exposure. The purpose of this chapter is to present normal physical, psychological, and behavioral outcomes of sexual trauma in both genders across the life span. As scientific knowledge of the internal biological changes wrought by all trauma expands, including natural and human-born disaster, future evidence-based care must challenge the entrenched habits of blaming victims of traumatic sexual abuse for their own suffering and focus on providing hope, evidence-based insight and viable options for empowered healing. Objectives By the end of this chapter, the reader will be able to: ——Define child abuse and maltreatment, domestic violence (DV), intimate partner violence (IPV), elder abuse, rape, and sexual violence. ——Relate the history of trauma to vulnerable populations. ——Describe the long-term functional biobehavioral outcomes of trauma exposure. ——Review current interdisciplinary strategies to prevent and treat traumatic exposure and consequences of abuse in vulnerable populations. Key Points 1. Not all negative health outcomes result from learned self-destructive lifestyle choices of trauma survivors; spontaneous unmitigated and functioning psycho- logical and physical changes, possibly permanent, occur after trauma exposure. 2. Irrespective of gender, sexual abuse, assault, and rape can and does occur in children, adolescents, adults, elderly, and intimate partners in any population, regardless of culture and socioeconomic status. 3. An increasing body of sexual trauma research supports association or relationship with a plethora of physical, psychological, and behavioral disorders. 4. Increased awareness of long-term and lingering health outcomes after sexual trauma is needed in the community of health care providers and other sexual response team members.
1 Sexual Assault: Victimization Across the Life Span, Second Edition, Volume 1: Investigation, Diagnosis, and the Multidisciplinary Team
5. Providing a trauma focused care from professionals responding to sexual trauma survivors can diminish the predictable cascade of negative health outcomes experienced through the life span. Key Terms ——The adverse childhood experiences (ACE) instrument is a tool that measures self-reported personal childhood emotional and physical abuse and neglect, childhood sexual abuse, along with a history of household illicit drug use, maternal battering, parental separation or divorce, and family member mental illness, incarceration, or attempted suicide.3 ——Child abuse includes “any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child.”4 ——Child sexual abuse is “the involvement of a child in a sexual activity that he or she does not fully comprehend, is unable to give informed consent to or for which the child is not developmentally prepared and cannot give consent to, or that violates the laws or social taboos of society.”5 ——A cultural group is a specific religious, racial, or ethnic group and any other group with its own distinct values, beliefs, and practices, “such as senior citizens, deaf and hard-of-hearing communities, populations with differing sexual orientations, the homeless, military personnel and their dependents, adolescents, prison inmates, and victims of sex trafficking.”6 ——Elder abuse is “a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person.”7 ——A first responder is a professional who responds in an official capacity to an initial disclosure of a sexual assault.6 ——Intimate partner violence is “physical, sexual, or psychological harm by a current or former intimate partner or spouse.”8 ——Military sexual trauma (MST) is defined as “psychological trauma, which in the judgment of a mental health professional employed by the Department [of Veteran Affairs], resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the Veteran was serving on active duty or active duty for training.”9 ——Rape is defined as “nonconsensual oral, anal, or vaginal penetration of the victim by body parts or objects using force, threats of bodily harm, or by taking advan- tage of a victim who is incapacitated or otherwise incapable of giving consent.”10 ——Sexual assault forensic examiner (SAFE) is a broad term for all health care providers (ie, physicians, physician assistants, nurses, or advance practice nurses [APNs]) who received specialized education and clinical training to conduct a forensic medical examination (FME) following sexual assault.11 ——Sexual assault nurse examiner (SANE) is defined as “a registered nurse who has advanced education in FME of sexual assault victims.”12 ——Sexual assault response team (SART) is a team of individuals, typically the SANE or SAFE, rape crisis center advocate, and law enforcement and emergency room (ER) medical personnel, who either work as a team at the time of the sexual assault examination or provide services independently but communicate frequently about cases.12 ——Sexual harassment is “repeated, unsolicited verbal or physical contact of a sexual nature, which is threatening in character.”9
2 Chapter 1: Health Consequences of Sexual Trauma Across the Life Span
——Sexual violence is defined by the World Health Organization (WHO) as, “any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic women’s sexuality, using coercion, threats of harm or physical force, by any person regardless of relationship to the victim, in any setting, including but not limited to home and work.”5 ——Survivor is a sexual assault victim who is involved in long-term healing.6 ——Trauma refers to a serious or critical emotional distress that threatens self- perception and identity, fundamental assumptions about the world, and connection to people and activities that were once meaningful.13 ——Vulnerable groups are individuals at greater risk of sexual assault and include women who are alone or single parents; children of all ages, especially those in foster care; all individuals in an abusive relationship or with a previous history of sexual abuse; individuals with physical or mental disabilities or drug or alcohol problems; incarcerated individuals; and those involved in prostitution, victims of war, and homeless populations.5 History Murder, incest, and rape with associated personal and social consequences are clearly described in some of the earliest accounts of human behavior (Genesis 19 and 32; Judges 19 [New International Version]). Although trauma from physical and sexual assault can be traced throughout the history of human life, legal action to protect children and the elderly from abuse was not established in the United States until late in the twentieth century.14 The first Federal legislation to protect children was enacted in 1974 by passage of the Child Abuse Prevention and Treatment Act (CAPTA), Public Law 93-247.15 The United States (US) Surgeon General C. Everett Koop declared violence a public health problem and intimate partner violence (IPV) an epidemic in 1985.16,17 Another decade and years of congressional hearings occurred before the Violence Against Women Act (VAWA) of 1994 was signed into law to protect women and their children from rape, IPV, and stalking.18 Public Law 102-585, Veterans Health Care Act of 1992, was amended by Public Law 103-452, Veterans Health Programs Extension Act of 1994, to establish programs to offer counseling and treatment for victims of military sexual trauma (MST).9 The Older Americans Act of 1965 established the Administration on Aging and laid groundwork for Title VII which provides state funding for protecting elders as a vulnerable population from abuse, neglect, and exploitation.19,20 Although attempts have been made to solidify general risk factors for abuse and neglect, sexual assault can happen to anyone of any age and gender (Table 1-1). Thus, enactment and enforcement of legal protection for those at greatest risk of traumatic abuse continues to evolve in the US and globally. Often hidden, early childhood and adolescent abuse is widespread and creates insidious lifetime potential for a plethora of adverse health outcomes.25 The World Health Organization (WHO) found 1% to 21% of women experienced child sexual abuse before 15 years of age.26 The National Intimate Partner and Sexual Violence Survey (NISVS) reported 1 out of 5 women and 1 out of 7 men in the United States experienced rape and the first rape often occurred before adulthood.27 In the Nurse’s Health Study II, 54% of registered nurses reported physical abuse and 34% acknowledged sexual abuse occurred during childhood or adolescence.28 Conversely, 18.4% of insured men reported childhood physical or sexual abuse.29 In the longstanding Adverse Childhood Experience (ACE) studies of health maintenance organization (HMO) enrollees, the frequency of childhood sexual abuse in females and males was lower, 25% and 16% respectively.30 Public awareness of child abuse was bolstered by publication of an article on the battered child syndrome.31 The Centers for Disease Control and Prevention (CDC) established definitions and guidelines that promote uniformity of data collected from research on violence.32 Increasing evidence of association between self-reported childhood abuse and detrimental health is strongly supported by numerous ongoing studies of adults spanning several decades21,25,33 (Table 1-2).
3 Sexual Assault: Victimization Across the Life Span, Second Edition, Volume 1: Investigation, Diagnosis, and the Multidisciplinary Team
Table 1-1. Risk Factors for Abuse of Vulnerable Populations
Group Risk Factor 95% CI Study
OR Upper Lower
Child On welfare 5.14 2.41 10.01 Brown et al21 abuse or Sociopathic mother 4.91 2.41 10.01 neglect Maternal dissatisfaction 3.15 1.81 5.48 Lack of parental involvement 3.14 1.51 6.54 Lack of maternal education 3.09 1.94 4.93 Low income 3.02 1.64 5.57 Early maternal separation 2.80 1.11 7.06 Not Caucasian 2.63 1.41 5.00 Lack of parental affection 2.57 1.43 4.62 Maternal youth 2.37 1.52 3.68 Maternal low self-esteem 2.28 1.02 5.07 Lack of maternal involvement 2.25 1.14 4.42 Single parent 2.09 1.31 3.33 Serious maternal illness 2.06 1.31 3.24 Difficult child temperament 2.02 1.05 3.91 Maternal alienation 1.97 1.27 3.07 Maternal anger 1.88 1.11 3.18 Large family 1.83 1.41 2.95 Poor marital relationship 1.70 1.06 2.71 Maternal external locus of control 1.64 1.05 2.56 No religious practice 1.62 1.52 3.68 Child Handicapped child 11.79 1.01 126.17 sexual Maternal sociopathy 6.27 2.31 17.06 abuse Negative family life events 4.43 1.82 10.80 Presence of non-biological father 3.32 1.18 9.34 Harsh punishment in the home 3.22 1.28 8.11 Unwanted pregnancy 3.10 1.29 7.45 Parental death 2.62 1.01 6.82 Female child 2.44 1.01 5.88 Maternal youth 2.26 1.01 5.08 Adolescent Prior severe physical aggression 15.24 4.06 57.09 Rickert et al22 rape from date Prior sexual victimization 4.70 1.89 11.72 Prior mild/moderate physical 4.27 1.45 12.56 aggression from date Alone at date’s home 3.01 1.36 6.67 (continued)
4 Chapter 1: Health Consequences of Sexual Trauma Across the Life Span
Table 1-1. Risk Factors for Abuse of Vulnerable Populations (continued)
Group Risk Factor 95% CI Study
OR Upper Lower
Female Pet abuse 7.59 1.61 35.96 Walton- intimate Perpetrator mental health fair/poor 6.61 4.00 10.43 Moss partner et al23 violence Former partner 3.33 2.02 5.49 Perpetrator alcohol abuse 2.77 1.60 4.78 Victim mental health fair/poor 2.65 1.59 4.49 Perpetrator not finish high school 2.06 1.16 3.66 Victim younger than 26 years old 2.05 1.18 3.57 Perpetrator drug abuse 1.94 1.11 3.39 Elder abuse New cognitive impairment 11.6 4.1 33.0 Lachs 24 and neglect Previous or new cognitive impairment 8.6 3.6 20.9 et al Non-white 5.1 2.5 10.4 Annual income less than $5000 3.8 1.8 8.3 New functional impairment 2.9 1.0 8.0 Education less than 8th grade 2.6 1.1 6.4 Two or more higher function impairments 2.3 1.0 5.2
Table 1-2. COLEVA: Consequences of Lifetime Experiences of Violence and Abuse
Allergies
——Multiple medication ——Environmental intolerance sensitivities
Behavioral Issues
——Alcoholism ——Decreased seat belt use ——Hoarding ——Illicit drug use ——Decreased helmet use ——Reduced compliance with medication and treatment ——Tobacco use ——Promiscuity
Cardiovascular
——Palpitations ——Atypical chest pains ——Increased risk of cardiovascular disease
Dental
——TMJ Disorders ——Avoidance of dental ——Poor dental hygiene care ——Increased cavities ——Bruxism ——Gingivitis ——Dental abscesses ——Increased tooth extraction rate
(continued)
5 Sexual Assault: Victimization Across the Life Span, Second Edition, Volume 1: Investigation, Diagnosis, and the Multidisciplinary Team
Table 1-2. COLEVA: Consequences of Lifetime Experiences of Violence and Abuse (continued)
Dermatology
——Unexplained pruritis ——Chronic excoriation-picking ——Neurodermatitis ——Chronic or recurring ——Alopecia-tricotillomania ——Delusional parasitosis urticaria
Endocrine
——Prolactin ——Elevated T3 levels ——Oxytocin-vasopressin ——ACTH-glucocorticoids ENT
——Dizziness ——Nasal Fractures ——TMJ disorders ——Ruptured TM ——Mandible fractures
Gastrointestinal
——Gastritis ——Pancreatitis ——Irritable bowel syndrome ——Unexplained ——Liver disease ——Chronic abdominal pain vomiting ——GERD ——Encopresis
General
——Sleep disorders ——Eating disorders ——Chronic fatigue ——Insomnia ——Obesity ——Risk of experiencing and/or ——Hypersomnia ——Anorexia perpetrating violence and abuse ——Bulemia
Genitourinary (GU)
——Urethritis ——Epididymitis ——Bladder dysfunction ——Prostatitis ——Interstitial cystitis ——Frequent bladder infections
Infectious Disease
——STIs ——Hepatitis B and C ——Increased risk of HIV
Mental Health
——Depression ——Panic disorder ——Cutting and other self-inflicted injury ——Anxiety ——Bipolar disorder ——Suicide/suicidal attempts ——PTSD ——Dissociative disorders ——Aggression/anger problems ——Hallucinations ——Obsessive-compulsive disorder ——Münchausen’s syndrome ——Schizophrenia ——Agorophobia ——Somatization syndrome ——Alexithymia
(continued)
6 Chapter 1: Health Consequences of Sexual Trauma Across the Life Span
Table 1-2. COLEVA: Consequences of Lifetime Experiences of Violence and Abuse (continued)
Neurological
——Syncope ——Pseudoseizures ——Increased risk of CVA ——Secondary to high-risk behavior ——Seizures ——Chronic daily ——Primary CVA-strangle headaches ——Altered sensations ——Dizziness/ ——Transient amnesia lightheadedness
Opthalmology
——Double vision ——Traumatic injuries ——Transient blindness
Ob-Gyn
——Vaginismus ——Premenstrual ——Less frequent dysphoric disorder self-breast exam ——Increased STIs ——Pelvic inflammatory ——Unnecessary surgical procedures ——Dyspareunia disease ——Post-partum depression ——Infertility ——Chronic ——Hyperemesis gravidarum ——Preterm labor and pelvic pain low birth weight ——Altered ovarian function ——Teen Pregnancies ——Early menopause ——Increased risk of ——Vulvodynia cervical cancer ——Complications of labor and delivery ——Abortion ——Prolonged labor ——Sexual dysfunction ——Spontaneous ——Greater need for medication ——Anorgasmia ——Therapeutic ——Increased risk of C-section ——Hypersexual
Orthopedics
——Chronic lower ——Increased risk ——Complex regional pain back pain of any fracture ——Neck strain/radiculopathy
Respiratory/Pulmonary
——COPD ——Choking ——Asthma exacerbation sensation/globus ——Real ——Increased risk of lung ——Perceived cancer ——Hyperventilation/ dyspnea
Rheumatology
——Fibromyalgia ——Chronic fatigue ——Auto-immune disorders ——Rheum. arthritis
Surgery
——Higher rate of ——More complications ——Increased surgical surgical failure from surgery procedures in general
Adapted with permission from McCollum D.34
7 Sexual Assault: Victimization Across the Life Span, Second Edition, Volume 1: Investigation, Diagnosis, and the Multidisciplinary Team
Abuse may be an isolated event or occur in cyclic waves throughout the life span. According to WHO, 13% to 61% of women sampled worldwide admitted experiencing physical violence and 6% to 59% reported sexual violence by a partner during life.26 In 1997, the CDC announced IPV as the leading cause of death in young women aged 15 through 24 years of age.16 Of adult women surveyed, 53.6% experienced physical or psychological IPV, or both, in their lives.35 Older women were not immune from IPV with 5.5% remaining in an abusive relationship,36 while 35.5% of those aged 50 through 56 years of age admitted IPV occurred sometime in adulthood37 and 26% of those aged 65 years or older also had lifetime IPV prevalence.38 Men reported 28% lifetime exposure to either physical contact abuse or nonphysical angry threats and control, but only 1% reported sexual IPV.29 Although female gender correlated with higher trauma scores than male gender,39 IPV occurred among diverse social, racial, and ethnic groups of all ages.40 Consistent with civilian reports, traumatic sexual abuse in the military occurs more among females than males. A larger percentage of female than male reservists reported military sexual harassment (60% versus 27.2%) and sexual assault (13.1% versus 1.6%).41 Abuse is not limited to a stereotypical weak victim; it can affect anyone targeted by an opportunistic or anger driven perpetrator. Long-term negative health consequences are strongly associated with MST.42 Review of the Literature The intent of this literature review is to create awareness among multidisciplinary teams, especially health care providers, about how sexual assault affects the victim’s health immediately and beyond. Long-term health effects associated with rape and sexual abuse have often gone unrecognized and untreated, even in premiere health care settings. The physical, neurobiological, mental health, and behavioral consequences of trauma are supported by research from numerous disciplines. The intent of the following section is to provide a quick reference for concerned professionals wanting to improve both personal and professional knowledge and trauma-informed care skills and to knowledgably respond to individual questions from survivors of sexual abuse who are on a quest to mitigate lingering effects of rape.
Physical Health Consequences of Trauma General Health Function Sexual, physical, and emotional abuse can affect the function of each body system and erode general health. As shown in Table 1-3, there are many physical health consequences of sexual trauma and the list is growing as researchers begin to understand the neurobiology of trauma across the life span. Diminished quality of life and perception of poorer general health occurs in adolescents and adults who experienced childhood sexual abuse (CSA) and other forms of childhood maltreatment. Adults of all ages who reported CSA had a combined significant and sustained decrease in health-related quality of life (P < .05) compared to adults who reported no childhood physical or emotional abuse or neglect.43 Adolescents and young adults who reported CSA were more than twice as likely to report fair to poor health (P < .001) than those who did not report any form of abuse or neglect.44 Adult HMO members who reported CSA (22%) also reported high rates of childhood psychological (47%) and physical (44%) abuse and household dysfunction (ie, 34% substance abuse, 37% mental illness, 41% maternal battering, and 40% incarceration). A significant dose- response relationship was found between the number and duration of adverse childhood experiences (ACEs) and risk factors for the leading causes of death in adults.45 Life expectancy decreased by 20 years (60.6 years versus 79.1 years) with exposure to 6 or more ACEs in HMO enrollees tracked over a decade.46 Although more studies have been conducted with women, adults of both genders who experienced IPV reported poor health. In a seminal study of both genders, the National Violence Against Women Survey found more sexual assault (24%) and
8 Chapter 1: Health Consequences of Sexual Trauma Across the Life Span
Table 1-3. Physical Disorders Reported with Sexual Trauma
Physical OR UCI LCI Gender Sample Trauma Evidence Age Study Disorder n Type (Years)
General 2.1 Both 479 CSA Self- 18-26 Hussey health report et al44 Both 6316 No abuse
Multiple 2.7 2.3 3.2 Both 2160 ≥ 4 ACEs Self- 57 Mean Anda somatic report et al47 symptoms Both 6255 No ACEs Poor 2.31 1.21 4.40 Female 300 Physical/ Self- 42 Mean Carbone- health sexual IPV report Lopez
et al48 1.87 0.70 5.03 Male 94 Physical IPV Female 5691 Other Male 5773 Other Fair to 1.88a 1.27 2.80 Female 322 Physical/ Self- 18-64 Bonomi poor sexual IPV report et al49
health Female 1838 No abuse
Attention 2.63 2.11 3.28 Female 29 418 MST Medical 18-65+ Kimerling deficit records et al50 4.07 3.38 4.89 Male 31 797 MST disorder and MST (ADD) self-report Impulse 3.40 2.39 4.84 Female control 3.23 2.64 3.95 Male problems Liver 1.66 1.35 2.03 Female disease 1.90 1.71 2.11 Male Sex 1.76 1.34 2.31 Female dysfunction 1.43 1.33 1.54 Male AIDS 1.38 0.88 2.17 Female
5.24 5.24 6.97 Male
Female 105 476 No MST Male 2 868 309 No MST
b Fatigue 9.2 4.0 21.5 Female 83 Severe Self- 18-64 Ciecha- PTSD report Dizziness 8.2 2.5 26.9 nowski with sexual, 51 physical, et al Numbness 3.3 1.2 9.3 emotional abuse
(continued)
9 Sexual Assault: Victimization Across the Life Span, Second Edition, Volume 1: Investigation, Diagnosis, and the Multidisciplinary Team
Table 1-3. Physical Disorders Reported With Sexual Trauma (continued)
Physical OR UCI LCI Gender Sample Trauma Evidence Age Study Disorder n Type (Years)
Headaches 6.5 2.8 14.9 Severe Self- Ciecha- PTSD report nowski TMJ pain 3.2 1.4 7.4 with et al51 Joint pain 3.2 1.4 7.4 sexual, physical, Back pain 2.0 1.2 3.4 emotion- al abuse Abdominal pain 3.6 1.5 8.5 Nausea 10.1 3.0 33.5 Diarrhea 2.9 1.1 7.8 Constipation 4.2 1.6 10.9 Dyspareunia 4.6 1.6 12.7 Premenstrual pain 3.2 1.4 7.3 Anhendonia 2.4 1.1 5.6 Anorgasmia 2.8 1.2 6.5 Short of breath 3.9 1.4 11.3 Chest pain 7.3 1.8 29.5 Female 843 No abuse Pelvic pain 7.60 1.60 36.0 Female 14 CSA Self- 40 Walker report Mean et al52 86 No CSA Chronic fatigue 2.0 1.7 2.4 Female 805 MST Self- 43 Frayne report Mean et al53 Back pain 1.6 1.4 1.9 Knee pain 1.6 1.3 1.8 Foot pain 1.5 1.3 1.8
Pelvic pain 2.1 1.7 2.6 Arthritis 1.7 1.4 2.0 Broken hip 2.4 1.0 5.4 Headaches 2.2 1.9 2.7 Vision loss 1.5 1.3 1.7 Hearing loss 1.7 1.4 2.1 Dysphagia 2.1 1.7 2.5 Indigestion 2.1 1.7 2.5 Bowel problems 2.0 1.7 2.3 (continued)
10 Index A Abnormality, 204, 300, 301 American With Disabilities Act (1990) (ADA), 114 ABO blood typing system, 140 Ammonia hydroxide, 152 Abortion, 100, 253 Anabolic steroids, 74 Academy on Violence and Abuse (AVA), 35 Anal anatomy, 208–209 Acid fuchsin (Baecchi’s stain), 150 Anal canal, 54 Acid phosphatase, 142–143, 316 Anal findings, 317 Acquired immune deficiency syndrome (AIDS), 17, 253 Anal human papillomavirus (HPV), 215 Adrenalin junkies, 101 Anal opening, 78, 78f Adrenarche, 54 Anal skin tags, 78, 208f Adrenocorticotropin hormone (ACTH), 15, 38 Anatomic variations in boys deficiency, 74 agenesis, 58 Adverse childhood experiences (ACEs), 2, 3, 8 circumcision adhesions and bridging bands, 57 Advocacy for improvement, 255 diphallia, 58 Advocates, 102, 254, 399 dorsal hood/chordee, 57 Agenesis, 58, 60 epispadias, 57 Age of consent, 110 erythema or hyperpigmentation, 57 Alcohol, 252 exstrophy of bladder, 57 Alcohol- or drug-facilitated sexual assault (ADFSA), 92, 404 hypospadias, 57 Alkaline phosphatase (ALK), 150 micropenis, 58 Allantoic diverticulum, 76 paraphimosis, 57 Alpha-naphthyl phosphate, 142, 148 penile torsion, 58 Alternative light source (ALS), 138, 146 phimosis, 57 suspect forensic examination, 345 reddish or pigmented macules, 57 Amastia seen in Poland syndrome, 70f smegma, 57 American Academy of Pediatrics (AAP), 316 urethral duplication, atresia, fistula, parameatal cysts or megalourethra, 58 American Association of Legal Nurse Consultants (AALNC), 233 urethral meatal stenosis, 57 The American Board of Forensic Odontologists (ABFO) uric acid crystals, 57 Ruler No. 2, 336 Anatomic variations in girls, 59 American Board of Forensic Odontology (ABFO), 188 hydrocolpos, 60 American Board of Forensic Odontology Diplomate labial hypertrophy, 60 (D-ABFO), 121, 129 labial hypoplasia, 60 American Board of Pediatrics (ABP), 223 linea vestibularis or midline sparing, 61 American Medical Association (AMA), 93, 239 ovary American Nurses’ Association (ANA), 93, 265, 285 bilateral absence, 61 American Professional Society on the Abuse of Children uterus, 62 (APSAC), 63, 65, 310, 314 paraurethral cysts, 61
Appendix, figures and tables are indicated by a, f, and t respectively
411 Sexual Assault: Victimization Across the Life Span, Second Edition, Volume 1: Investigation, Diagnosis, and the Multidisciplinary Team
partial androgen insensitivity syndromes, 59–60 Antemortem human bite mark, 125f partial or complete virilization, 59 Antibody-based assays, 143 PEARL, 61 Antibody binding–based assays, 138, 143–145, 148, 150, 152 prolapse, 61 Antidepressants, 31 Skene’s duct cysts, 61 Anti-Müllerian Hormone (AMH), 55 urethral caruncle, 61 Anus, 54, 314–316 uterine anomalies and absence of cervix, 61 Anxiety disorders, 21–25 vaginal agenesis, 60 Appointment of counsel, 388 vaginal atresia, 60 Arraignment, 388, 397–399 vaginal duplication, 60 Arrhythmias, 20 vaginal prolapse or procidentia, 60 Aspermia, 138 Androgen insensitivity, 56 Assent, 110, 114, 117 Angioedema, 56f Athelia, 70 Annular hymen Attention deficit disorder (ADD), 14 orifice, 63f, 64f AVA. See Academy on Violence and Abuse (AVA) showing anterior column, 65f Anogenital anatomy B anorectum, 76–79 Backlog of evidence collection kits, 190–192 healing following genital and perianal injuries, 79–81 Bad acts, 401 variations, 79 BALD STEP, 340 external genitalia Behavioral consequences, sexual trauma, 27 in boys, 56–58 eating disorders, 32 in girls, 58–62 employment, financial, and residential instability, 33 hymen, 62–68 risky sexual behaviors, 32 medical embryology of the external genitalia, 55 self -harm and suicide, 33–34 puberty, 69–76 sleep disorders, 32–33 Anogenital injury, 211 substance abuses, 27–32 Anogenital trauma, 209 troubled relationships, 33 Anonymous testing, 394 violence, 33 Anorectum, development, 76 Behcet syndrome, 221 anatomical variations Biomarkers, 138 anal opening, 78 Bipolar disorder, 27 anal tags, 78 Bipolar symptoms, 27 diastasis ani, 78 Bite mark evidence, 121–122 Infantile perianal pyramidal protrusion, 78 bite mark microscopy, 134 midline perineal fusion defect, 78 impression, 133–134 superficial fissures, 79 management, 129–131 color changes permanent positive replicas, 134 black, 77 photography, 131–133 blue, 77 recognition brown, 77 classic presentation, 123–126 red, 77 common presentations and problems, 127–129 white, 77 types, 122 normal perineum, 76–77 in suspect forensic examination, 340 variations Bleeding, 210 cloacal exstrophy, 79 diatheses, 221 imperforate anus, 79 Blistering disorders, 213–214 urogenital sinus anomalies, 79 Blood, 151–152 and urine samples, suspect forensic examination, 350, 350f 412 Index
Bloodstains, 180 human papillomavirus, 215–217 Body fluid identification, 161 Molluscum contagiosum, 218 Breast tissue, 69 pinworms, 219 Brentamine Fast Blue, 148 schistosomiasis, 218 Broken bones, 253 vaginal foreign body mimicking infection, 220 Bruising, 210 vulvovaginitis, 214–215 Buccal cavity, swabbings of, 180f inflammatory disorders Bullous lesions, 212 Behcet syndrome, 221 Bureau of Justice Statistics (BJS), 396 Crohn’s disease, 221 Buttock, perineum, anal, and rectal examination Kawasaki syndrome, 221 suspect forensic examination, 349, 349f legal implications of differential diagnosis, 223 miscellaneous disorders, 221 C hair tourniquet syndrome, 222 Canalization of urethra, 58 idiopathic calcinosis cutis, 221 Cancer Genome Anatomy Project (CGAP), 160 labial adhesions, 222 Candida albicans, 220 mimics of bruising, 221 Capacity, 110, 114–116 rectal prolapse, 222 Cardiovascular function, 20 urologic conditions, 221–222 arrhythmias, 20 nonabusive trauma, 209–211 Caregivers, 300 variations of normal anatomy, 203–204 statements and questions by, 303–304 anal anatomy, 208–209 Cellular material, 348 genital anatomy, 204–207 Centers for Disease Control and Prevention (CDC), 3, 35, Christmas tree stain, 138 38, 113, 215 Chronic disease, 74 Central nervous system (CNS), 68 Chronic norepinephrine, 21 Cervix, 54, 61, 71 Chronic traumatic stress, 15 Chain of custody, 170, 171f, 190 C+I=M. See Custody+interrogation=miranda warnings Chemical reaction–based assays, 138, 142, 151, 154 (C+I=M) Child abuse, 2, 3, 16, 21 Circumcised male anatomy, 318f mandatory reporting, 269 Circumcision adhesions and bridging bands, 57 medicine and law, overlap in, 223 Clayton, 78f normal and nonspecific findings in suspected, 203t–204t Clinical cultural competence, 90 Child Abuse Prevention and Treatment Act (CAPTA), 3 Clippings, 181 Childhood sexual abuse (CSA), 8 Clitoris, 54 Child protective services (CPS), 202, 300 isolated enlargement, 59 Child sexual abuse, 2 in premature infant, 59f dermatologic disorders Cloacal exstrophy, 79 blistering disorders, 213–214 Closed-ended questions, 384 contact dermatitis, 213 Clothing, 177–180 hemangiomas, 213 collection, suspect forensic examination, 340 lichen sclerosus et atrophicus, 211–212 CODIS. See The Combined DNA Index System (CODIS) psoriasis, 213 COLEVA, 5t–7t seborrheic dermatitis, 212 Colloidal gold-conjugated antibody, 144 differential diagnosis, 201–203 Colposcope, 194 examination, 202 The Combined DNA Index System (CODIS), 337 infectious disorders, 214 Community-based services, 254 Candida albicans, 220 Community effectiveness, 290 genital ulcerative lesions, 217 Community SART response and responsibilities, 269 Group A streptococcus, 215 Competency, 110
413 Sexual Assault: Victimization Across the Life Span, Second Edition, Volume 1: Investigation, Diagnosis, and the Multidisciplinary Team
Confirmatory test, 138 D Confocal laser microscopy (CLM), 134 Dane’s staining technique, 153 Consent, 170, 175–176 Daubert v Merrell Dow Pharmaceuticals, Inc., 244 cycle, 110 2-D difference in gel electrophoresis (2D-DIGE), 155 evidence collection from victims, 175–176 Debris and foreign materials, 180 form, 176f Degree of elasticity and distensibility, 313 legal issues, prosecutor’s perspective, 388–391, 400, 401, 403 Dehydroepiandrosterone (DHEA), 73 suspect forensic examination, 338 Dental floss, 188 Contact dermatitis, 213 Dentate/pectinate line, 77 Contusions, 253 Denticular hymen orifice, 63f Copious white discharge, 220f Deoxyribonucleic acid (DNA), 112, 139, 217 Corroborating evidence blood and urine samples, 350 law enforcement issues, 364, 373–374 buccal swab, 346 Corticotrophin-releasing factor (CRF), 15 cellular material, 348 Court order. See Search warrants fingernails, 347–348 Court system, 231 law enforcement issues, 364, 366, 367 expert witness, 232 as reference, 336–337 nurse as expert witness, 233–234 screening, 360 participants, 231–232 suspect’s, 340 preparing for trial, 234 victim’s, 337 trial proceedings, 234–235 See also DNA Cowper’s gland, 147 Department of Justice (DOJ), 34, 169, 173 Crescentic hymen, 206f Deposition, testifying in court, 235 orifice, 64f active listening, 236–238 Cribriform hymen, 64f after, 241 Crime laboratory personnel, 102 duces tecum, 235–236 Crime scene giving deposition, 236 evidence, 356 identifying poorly formed questions, 238–239 regarding body fluids, 359–360 instruction, 236t regarding clothing, 358 questioning, goal of, 239 regarding wounds, 359 subpoenas, 235 law enforcement issues, 364–369 testing case facts and field expertise, 240 Crime Scene Investigation technicians, 180 testing knowledge sources, 241 Crime Victim’s Boards for Compensation, 357 Depression, 15, 17, 26, 56, 76, 78 Criminal justice process, 389 Dermatologic disorders, child sexual abuse legal issues, prosecutor’s perspective, 396, 396f blistering disorders, 213–214 Criminal prosecution contact dermatitis, 213 police role, 384–385 hemangiomas, 213 Crohn’s disease, 221 lichen sclerosus et atrophicus, 211–212 Cross-examination, areas of inquiry on, 245t psoriasis, 213 Cultural group, 2 seborrheic dermatitis, 212 Culturally and Linguistically Appropriate Service (CLAS), 92 Diabetes mellitus, 18 Custody+interrogation=miranda warnings (C+I=M), 364, 370 Diaper dermatitis, satellite lesions characteristic of, 220f Cystic fibrosis (CF), 222 Diastasis ani, 78, 208f Cytochrome c oxidase, 151 Dienestrol, 60 Cytochrome P450, 151 Differential diagnosis, 202, 214 Cytosine-phosphate-guanine (CpG), 161 genital trauma, 316 See also Child sexual abuse
414 Index
5-dihydrotestosterone (5-DHT), 55, 56 Emergency Nurses Association (ENA), 233 Diisopropylbenzene dihydroperoxide, 152 Emergency physicians, 101 Diphallia, 58 Emergency room (ER), 263, 305 Direct testimony, 243t Emotional care, 286 Disassociation, 26 Emotional function, 20 Discharge planning, 100–101 Emotional support and crisis intervention, 267 Discovery (litigation), 235 Emphysema and asthma, 19 Dispatchers, 380 Employment, financial, and residential instability, 33 District Attorney (DA), 232 Endocrine disruption, 17 Diversity, 90 Endocrine function, 17–18 DNA End Violence Against Women International (EVAWI), 103 databases, 251 Enterococcus, 214 methylation, 161 Enzyme activity–based assay, 138, 142–143, 150 profiling, 142 Enzyme-linked immunosorbent assays (ELISA), 148 samples, 180 Ephemeral, 122, 133 testing, 251, 257 Epididymis, 54–56, 147 See also Deoxyribonucleic acid (DNA) Epigenetic markers, 161 Dorsal hood/chordee, 57 Epigenetics, 138 Double-swab technique, 187 Epispadias, 57 suspect forensic examination, 339 Epithelial cells 2-D polyacrylamide gel electrophoresis (2DGE), 155 light/fluorescence microscopy–based assays, 145 Dried saliva secretions, 187 suspect forensic examination, 336, 349 Drug-enabled sexual assault (DESA), 110 vaginal, 153, 154 Drug-facilitated sexual assault (DFSA), 110, 187 Erythema, 210, 319 Drugs, 252 hyperpigmentation, 57 Dysmenorrhea, 18, 21 multiforme, 221 Dysuria, 17, 214, 222, 304, 314, 319 vestibular sulcus of, 66 Estrogen, 54 E Estrogenized hymen, 68f Easy accessibility services, 255 Evidence collection from victims, 169–170 Eating disorders, 32 care, current practices in, 192 Ecchymosis, 210 anonymous reports, 192–193 Elder abuse, 2 DNA, use of, 193 Emergency contraception, 100, 266, 287 nonreports to law enforcement, 192 Emergency department (ED), 193, 284 reports to law enforcement, 192 Emergency medical service (EMS) providers, 36 current evidence base, 174 crime scene evidence, 358–359 alternate light sources, 188 first responders, 381 backlog of evidence collection kits, 190–192 forensic evidence, 357 bloodstains, 180 crime scene evidence, 358–360 chain of custody, 190 physical assessment, 357 clothing, 177–180 victims’ behavior, 357–358 consent, 175–176 rape trauma syndrome, 356–357 debris and foreign materials, 180 sexual assault forensic examiner (SAFE), 356, 360 dental floss, 188 sexual assault nurse examiner (SANE), 356, 360 DNA samples, 180 sexual assault response team (SART), 356, 360 dried saliva secretions, collection of, 187 transporting victims to hospitals, 360–361 fingernail clippings and scrapings, 181–185 victim psychology, 356–357 known hair samples, 185
415 Sexual Assault: Victimization Across the Life Span, Second Edition, Volume 1: Investigation, Diagnosis, and the Multidisciplinary Team
management and storage, 190 crime scene evidence, 358–360 photography, 188–190 physical assessment, 357 sexual assault evidence collection kit, 174–175 reasons for lack of testing of, 190t swabs and smears, 185–187 victim behavior, 357–358 toxicology, 187 Forensic medical examination, police role, 378 history, 170–172 Forensic nurses, 249, 338 United States National Protocol 2013, 173–174 Forensic serology, 137–140 literature, 174 general categories of serological testing, 142 Evidence collection kit process, 185 antibody binding–based assays, 143–145 Examiner-applied traction, 210 blood, 151–152 Exigent circumstances, 116 chemical reaction–based assays, 142 Expert witnesses, statute of limitations enzyme activity–based assays, 142–143 criminalistics, 403 light/fluorescence microscopy–based assays, 145–146 developmental disabilities, 403 saliva, 150–151 medical, 402–403 seminal fluid and spermatozoa, 147–150 mental health, 404 serological tests for specific body fluids, 146–147 toxicology, 403 urine and fecal matter, 152–153 victim behavior, 403 vaginal fluid, 153–154 Exstrophy of bladder, 57 history and relevance, 140–141 External vaginal ridge, 65 research and development, 155 Extragenital trauma, 321 epigenetic markers, 161 mRNA and miRNA biomarkers, 160 F protein biomarkers and mass spectrometry, 155–159 Facial hair combing or swabbing, 346, 346f Raman spectroscopy, 161–162 Failure of midline fusion, 207f scientifically rigorous reporting, 154–155 Federal Rule of Civil Procedure, 235 sexual assault and Locard principle, 140 Female technological demands and practitioner responsibilities, anatomy, 312f 141–142 genitalia, 186f Forensic toxicology testing, 255 pseudohermaphroditism, 59 Foreskin, 54 pudendum, 58 Fossa navicularis, 54 Feminizing adrenal or testicular tumors, 74 Foul-smelling discharge, 220 Fibroids, 253 Frog-leg position, 307, 308f Fimbriated hymen, 63, 63f Fingernails G clippings and scrapings, 181–185 Group A beta-hemolytic streptococcus, 214 suspect forensic examination, 347–348, 347f Group A beta-hemolytic streptococci perianal disease, 77f Fingerprints, 255 Gamma-Hydroxybutyric acid (GHB), 194 First responder, 2 Gartner duct cyst, 61f See also Police role Gastrointestinal function, 16–17 Fissures, 212 Gender-based violence (GBV), 89–91 Flow immunechromatographic strip tests, 149, 149f cross-cultural care, overarching principles for, 102–103 Fluorescence, 139 historic cultural and linguistic developments, 91–93 Focal erythema, 220f MFE Follow-up examination, 204 consideration after, 100–101 Force, legal issues, 388, 390–391 consideration before, 93–98 Forensic effectiveness, 288 consideration during, 99–100 Forensic evidence professional biases, 101–102
416 Index
professional guidelines and standards, 92–93 Herpes simplex virus type 1 (HSV-1), 217 regulatory impact, 92 Herpes simplex virus type 2 (HSV-2), 217 state licensure requirements, 92 High performance liquid chromatography (HPLC), 156 General assessment, suspect forensic examination, 340, Honor killing, 250, 253 341f–344f Hospital-based or hospital-affiliated services, 253 Generic immunochromatographic strip test, 144f Hospital-based SANE Programs, 268 Genetic sex, 55 Human bite marks, 123f, 124f Genital anatomy, 204–207 by adult dentition, 126f Genital examination, suspect forensic examination, 348, 349f with nipple avulsion, 130f Genital fondling, 313, 319 Human immunodeficiency virus (HIV), 19, 252–253, 285 Genital irritation, 253 Human papillomavirus (HPV), 215–217 Genital sequelae, 382 infection, 68 Genital-to-anal contact, 321 Human semen, 147 Genital trauma, 312 Hydrocolpos, 60 Genital ulcerative lesions, 217 Hymen Genital ulcers, 217 normal, features, 65–66 Genotypic female, 59 types, 62, 63 Gilbert-Dreyfus, 56 variations in configuration, 62–64 Glans penis, 54 estrogen at birth and during puberty, 68 Glucose metabolism, 18 features, clinical, 65–68 Glycoprotein, 55 prevalence in studies, 65 Gonadotropin-releasing hormone (GnRH), 72 Hymenal bumps, 66, 206f Grooming, 388, 392, 395 Hymenal membrane, 311–314, 319 Group A streptococcus, 215 Hymenal notches, 65–66 Group-specific component (Gc), 140 Hymenal orifice, 313 Gynecomastia, 73 Hymenal septum, remnants following lysis, 64f Hymenal skin tags, 204, 206f H Hymenal tags, 65 Haemophilus influenzae, 214 Hymen involutes, 311 Hair tourniquet syndrome, 222 Hyperthyroidism, 74 Hands, suspect forensic examination, 346–347, 347f Hypospadias, 57 Headaches, 15–16 Hypothalamic-pituitary-adrenal (HPA), 15, 17 Head hair combing and collection, 345, 345f Hypothalamic pituitary gonadal axis, 73 Head-to-toe assessment, 188 Healing I genital and perianal injuries, 79–81 Idiopathic calcinosis cutis, 221 laceration, 80f Idiopathic thrombocytopenic purpura (ITP), 221 Health Insurance Portability and Accountability Act Immune and hematologic function, 19 (HIPAA), 113 Immunochromatographic strip test, 144f, 152 Health literacy, 90 Impaired auditory and visual function, 16 Health maintenance organization (HMO), 3 Imperforate anus, 79 Hemangioma, 213, 221 Imperforate hymen, 62f Hematoxylin, 150 Imperforate hymen with hematocolpos, 207f Hemorrhage, 212 Implied consent (emergency doctrine), 110 Hemorrhoids, 77 Incapacitated sexual assault/rape, 110 Henoch-Schonlein purpura, 221 Increased aromatase activity, 74 Hermaphroditism, 74 Inculpatory, 110 Herpes simplex virus (HSV), 214, 217 Infantile perianal pyramidal protrusion (IPPP), 78, 78f
417 Sexual Assault: Victimization Across the Life Span, Second Edition, Volume 1: Investigation, Diagnosis, and the Multidisciplinary Team
Infectious disorders, child sexual abuse, 214 practices, 255 candida albicans, 220 public policy, 251 genital ulcerative lesions, 217 Interview process, law enforcement issues Group A streptococcus, 215 C+I=M, 370 human papillomavirus, 215–217 criminal history, 370 Molluscum contagiosum, 218 handwriting exemplar, 371 pinworms, 219 on-scene investigatory practices, 369 schistosomiasis, 218 strategies, 371 vaginal foreign body mimicking infection, 220 trained sexual assault investigator, 370 vulvovaginitis, 214–215 victim, guidance on interviewing, 371–372 Infertility, 253 Intimate partner, 250 Inflammatory disorders, child sexual abuse Intimate partner violence (IPV), 1–3, 252 Behcet syndrome, 221 first responder, 379 Crohn’s disease, 221 Intravaginal ridges, 65f Kawasaki syndrome, 221 Intravenous (IV) drugs, 31 Information-gathering skills, 302 Investigative follow-up and interviews, police role, 383–384 Informed consent, 109–111 Involuntary self-inflicted bite marks, 122 adolescents, 114 IPPP. See Infantile perianal pyramidal protrusion (IPPP) children, 114 Irritable bowel syndrome (IBS), 16 history, 111 Irritation, 58, 60, 66, 210, 213, 214, 253 incapacitated patients, 115 intellectually and mentally impaired patients, 114–115 J medical forensic evaluation, 112 Joint Commission on the Accreditation of Health Care benefits, 112 Organizations (JCAHO), 264 medication, 113–114 Joint interview SART Model, 273–274 photodocumentation, 113 coordinated model, 274–275 release of personal information, 113 limitation, 274 risks, 112 Jurisdiction protocols, 339 in sexual assault care setting, 111–112 Jury selection, statute of limitations, 401–402 suspect examinations, 116 Juvenile prostitution, 31 unconscious patient, 115–116 Inguinal freckling, 77f K Intensive care unit (ICU), 95 Kastle-Meyer (KM) test, 151 International Association of Forensic Nurses (IAFN), 173, for blood, 142 251, 265 Kawasaki syndrome, 221 International Criminal Police Organization (INTERPOL), 251 Klinefelter syndrome, 74 International systems response to sexual violence, 249–250 Knee-chest position, 308f challenges, 256–257 Known hair samples, 185 cooperation and collaboration, 250–251 current evidence-based state of the science, 254–255 L DNA databases, 251 Labial adhesions, 222 global perspective, 252 Labial agglutination, 66, 320–321 consequences, 252–253 Labial hypertrophy, 60 incidence, 252 Labial hypoplasia, 60 societal costs, 253 Labial traction, 207 models of victim services, 253 Labia majora, 54 advocate- or community-based services, 254 Labia minora, 222 hospital-based or hospital-affiliated services, 253 Lacerations, 253 medicolegal-based services, 253–254 Lack of sexual desire, 253 418 Index
Lactobacillus acidophilus (L. acidophilus), 71, 72 sexual assault forensic examiner (SAFE), 388, 393–395 Langer lines, 122 sexual assault laws in United States, 390–391 Law enforcement issues sexual assault nurse examiner (SANE), 388, 393, 395, 402 case documentation and management, 374 sexual contact crimes, 391 communication, 374–375 sexual exposure crimes, 389, 391 corroborating evidence, 364, 373–374 sexual penetration crimes, 389–391 crime scene, 364–369 statute of limitations, 389, 397–404 custody + interrogation = miranda warnings (C+I=M), victim rights, 390 364, 370 Leucomalachite Green (LMG) tests, 151 deoxyribonucleic acid (DNA), 364, 366, 367 Leydig cells, 54 department policy, 374 Lichen sclerosis, 77f fruits of the poisonous tree, 364, 366 Lichen sclerosus et atrophicus, 211–212, 212f interview process, 369–372 Light/fluorescence microscopy–based assays, 139, 145–146, 149 law enforcement officers, 364 Linea vestibularis, 61, 66, 204, 205f Locard’s exchange principle, 364, 367 Linguistic competence, 90 scene and collecting evidence, processing Liver function, 17 blood-detecting chemicals, 368 Locard, Edmond, 170 crime scene report, 369 principle, 140 DNA analysis, 367–368 Longitudinal intravaginal ridges, 65 guidelines for, 368 Lub’s syndromes, 56 latent fingerprints, 368 Lymphoid follicles, 67 legal permission, 366 organized search team and appropriate resources, 366–367 M outdoor scenes, 367 Magnetic resonance imaging (MRI), 14 photographs and measurements, 367–368 Male genitalia, 317–318, 318f steps, 365–366 Male pseudohermaphroditism, 56 vehicle identification, 368 Management and storage of evidence, 190 search warrants, 372–373 Mandatory reporting, 269 sexual assault response team (SART), 364, 374 Marijuana, 74 suggestions for investigators, 375 Marsupialization, 61 Law enforcement personnel, 102 Mass spectrometry, 139 suspect forensic examination, 340 Matrix-assisted laser desorption ionization (MALDI)-TOF, 159 Lawson Wilkins Pediatric Endocrinology Society Task Force, 73 MDT. See Multidisciplinary team (MDT) Legal effectiveness, 289 Median raphe, 204, 205f Legal implications, 202 Medical effectiveness, 287–288 Legal issues, prosecutor’s perspective Medical forensic examination (MFE), 91 appointment of counsel, 388 health literacy, 93 arraignment, 388, 397–399 photographic imaging, 99–100 common defenses, 404–405 Medication, 74, 113–114, 213, 239, 264, 277 consent, 388–391, 400, 401, 403 Medicolegal-based services, 253–254 criminal justice process, 396, 396f Menstrual fluid, 156, 160 dynamics of sexual assault crimes, 391–393 Mental health consequences, 253 force, 388, 390–391 Metastatic Crohn’s disease, 221 grooming, 388, 392, 395 Methylene blue, 150 investigation, 394–396 Metropolitan Organization to Combat Sexual Assault probable cause, 388, 397, 399–400 (MOCASA), 273 rape shield, 388, 400–401 MFE. See Medical forensic examination (MFE) sexual assault forensic exam, 393–394 Micropenis, 58
419 Sexual Assault: Victimization Across the Life Span, Second Edition, Volume 1: Investigation, Diagnosis, and the Multidisciplinary Team
Micro RNAs (miRNA), 160 Normality, 300 Midline perineal fusion defect, 78, 78f Nurse practitioners (NPs), 223, 285 Mid parental height expectation (MPHE), 73 Military sexual trauma (MST), 2, 3 O Mimics, 202 Offender-focused investigations, police role, 382–383 of bruising, 221 Office for Victims of Crime (OVC), 34, 265, 272 Minneapolis-based Sexual Assault Resource Service, 265 Office of Justice Programs (OJP), 34 Minor laceration of scrotum/penis, 210 Oligospermia, 139 Model Rules of Professional Conduct (MRPC), 397 Ongoing contact and victim support, police role, 385 Models of victim services, 253 On-scene first responders, 380 advocate- or community-based services, 254 On-scene investigatory practices, 369 hospital-based or hospital-affiliated services, 253 Open-ended questions, 384 medicolegal-based services, 253–254 Optically tunable, 139 Molluscum contagiosum, 218 Oral Mongolian spots, 221 penetration, 390–391 Mons pubis, 54, 58 suspect forensic examination, 346, 346f Moraxella catarrhalis, 214 Ovary, 54 mRNA and miRNA biomarkers, 160 bilateral absence, 61 MRPC. See Model Rules of Professional Conduct (MRPC) Mucocutaeous lymph node syndrome. See Kawasaki syndrome P Müllerian inhibitory factor (MIF), 55 Painful intercourse, 253 Multidimensional spectroscopic signatures, 161 Pain perception, 15 Multidisciplinary services, 255 Pain pills, 31 Multidisciplinary team (MDT), 196, 266, 290, 305, 378, 380 Paraphimosis, 57 Musculoskeletal function, 16 Paraurethral cysts, 61 Myelomeningocele, 222 Partial androgen insensitivity syndromes, 59–60 Partial or complete virilization, 59 N Patient-centered care, 97 National Electronic Injury Surveillance System—All Injury Patulous anus, 315 Program (NEISS-AIP), 35 p-dimethylaminocinnamaldehyde (DMAC), 152 National Health and Nutrition Examination Study PEARL, 61 (NHANES III), 69 Pelvic inflammatory disease (PID), 71, 253 National Institute of Justice (NIJ), 272 Penetrating injuries, 210 National Intimate Partner and Sexual Violence Survey Penile and scrotal swabbing, 349, 349f (NISVS), 3, 35 Penile swabbing, 349 National Violence Against Women Survey, 21 Penile torsion, 58 Neisseria meningitides, 214 Penis, 54, 58, 74, 210 Neurologic abnormalities, 222 Perianal erythema, 208, 215f Neurologic and cognitive function, 14–15 Perianal pigmentation, 208 pain perception, 15–16 Perineum, 54, 310 Neutrophil gelatinase, 157 Peripheral blood, 156 Nonabusive trauma, 209–211 Periurethral and perihymenal vestibular bands, 66 urogenital injuries, 211 Personality disorder, 27 Nonblood hemoprotein, 152 Personal privacy, 307 Nonmedical Community-based SANE Programs, 268 Phenolphthalein, 142 Non-report sexual assault examinations, 269 Phimosis, 57, 212 Nonstranger perpetrators, 382–383 Phobia and panic disorders, 25–26 Normal genitalia, 310 Phosphoglucomutase (PGM), 140 420 Index
Photodocumentation, 113 grand jury proceedings, 400 Photography, 188–190, 191f probable cause (preliminary) hearing, 399–400 suspect forensic examination, 339, 339f victim advocate, 399 Physical evidence, 170 victim-witness assistant, 399 Physical health consequences, 8–14 hearing, 399 Pink pearly papules of penis, 74, 74f Proctological disorders, 315 Pinworm infestation (Enterobius vermicularis), 219, 219f Professional interpreters, 97–98 Plea negotiations, statute of limitations, 398–399 Prolactinoma, 74 Poland syndrome, amastia seen in, 70, 70f Prolapse, 61 Police dispatchers, 380 of urethra, 221 Police role Prone knee chest position, 207f criminal prosecution, 384–385 Prosecutors, 102 flash information, 378 Protected health information (PHI), 113 forensic medical examination, 378, 383 Protein biomarkers, 157 investigative follow-up and interviews, 383–384 Protein biomarkers and mass spectrometry, 155–159 multidisciplinary approach, 378 Proteome, 139 multidisciplinary team (MDT), 378 Proteomics, 156 offender-focused investigations, 382–383 Psoriasis, 213 ongoing contact and victim support, 385 Psychological and physical trauma, 381 preparation for, 379 Psychological consequences, sexual trauma trauma and victim reactions, 381–382 anxiety disorders, 21–25 victim-centered response, 378 bipolar disorder, 27 victim contact, 379–381 depression, 26 Polymerase chain reaction (PCR), 160, 217 disassociation, 26 Polyp, 221 emotional function, 20 Posterior hymen, 81f personality disorder, 27 Postmenopausal lichen sclerosis, 60 phobia and panic disorders, 25–26 Postmortem dilation, 209 posttraumatic stress disorder, 21–25 Posttraumatic stress disorder (PTSD), 21–25 schizophrenia and psychoses, 27 in victim reaction training, 382 somatization, 26–27 P30/PSA immunochromatographic lateral flow test strip, 144f Psychological effectiveness, 286–287 Preejaculatory fluid, 147 Psychotherapy, 35 Prehospital care providers. See Emergency medical service (EMS) providers Pubarche, 54 Preliminary arraignment Puberty, 55, 60, 312 bail, 398 females, 69 community safety and victim safety, 398 cervix, 71 defendant’s prior criminal history, 398 external genitalia, 71–72 Preliminary hearing, 399 internal genitalia, 71 Premature mortality, 20 precocious puberty, 70 Prepubertal children, 307 pubarche and adrenarche, 70–71 speculum examination, 309 thelarche, 70 Prepuce (foreskin), 58 males, 72–73 Pre-SANE program, 287 pubertal variations, 73–74 Presumptive test, 139 sexual maturity rating, 75–76 Pretrial motions, statute of limitations, 400–401 Pubic hair, 69 Probable cause, 388, 397 suspect forensic examination, 348–349, 348f determination, statute of limitations Pudenda, 310 definition, 399 Pyridine hemochromogen, 151 421 Sexual Assault: Victimization Across the Life Span, Second Edition, Volume 1: Investigation, Diagnosis, and the Multidisciplinary Team
Q Search warrants Quadrupole-time of flight mass spectrometer law enforcement issues, 372–373 (Q-TOF), 157, 157f suspect forensic examination, 336–338, 348, 349 Questioning of witnesses, 234–235 Seborrheic dermatitis, 212 Secondary victimization, 283 R Secure Digital Forensic Imaging Web site, 347 Raman spectroscopy, 139, 161–162 Sedatives, 31 Rape, 2, 110 Self -harm and suicide, 33–34 Rape crisis centers (RCCs), 263 Seminal acid phosphatase (SAP), 148 Rape shield, 388, 400–401 Seminal fluid, 139, 140, 156 Rape trauma syndrome (RTS), 356–357 and spermatozoa, 147–150 Rapists, 115 Seminal vesicle, 55 Rectal ampulla, 77 Septal remnants, 204 Rectal polyps, 222 Septate hymen, 64f, 207f Rectal prolapse, 222 orifice, 64f Rectum, 55 with hemangioma, 206f Reddish or pigmented macules, 57 Serial photography, 122 Regional networks of forensic science, 251t Serological tests for specific body fluids, 146–154 Registered nurse (RN), 337–338 Sertoli cells, 55 Reifenstein, 56 Sex-determining region (SRY), 55 Representative saliva proteome map, 156f Sexual abuse, child and adolescent victims, 299–300 Reproductive disorders, 18 accidental injuries, 320 Research-grade optical stereomicroscope, 122 labial agglutination, 320–321 Respiratory function, 19–20 examination positions and techniques, 307–309 Risk factors for abuse of vulnerable populations, 4t–5t forensic evidence, 323–324 Risky sexual behaviors, 32 formulating a diagnosis, 327–330 RTS. See Rape trauma syndrome (RTS) genital and anal anatomy, 310 anus, 314–316 S hymenal membrane, 311–314 SAFE. See Sexual assault forensic examiner (SAFE) vagina, 310 SAKs. See Sexual assault examination kits (SAKs) vaginal vestibule, 310–311 Saliva, 150–151, 156, 160 healed and healing injuries, 322–323 SANE. See Sexual assault nurse examiner (SANE) indications for physical examination, 304–306 SANE-SART efficacy medical conditions, 324 collaboration, 275 medical examination, 300–301 forensic evidence collection, 276–277 medical record and diagnostic conclusions, 324–325 higher reporting rates, 275–276 documenting the clinical evaluation, 325–326 medical care, 277 medical history, 326–327 prosecution, 277–280 medical record, 326 shorter examination time, 276 patterns of trauma, 318–319 SART. See Sexual assault response team (SART) genital fondling, 319 Satellite lesions characteristic, diaper dermatitis, 220f vaginal penetration, 319–320 Scanning electron microscopy (SEM), 134 vulvar coitus, 319 Schistosomiasis, 218 preliminaries to conducting the medical examination, Schistosoma haematobium, 218 301–304 Schizophrenia, 27 preparing child for physical examination, 306–307 and psychoses, 27 residual effects from sexual contact, interpreting, 316–317 Scrotum, 55 anal findings, 317
422 Index
male genitalia, 317–318, 318f Sexually transmitted infections (STIs), 17, 113, 252, 266, sexually transmitted infections (STI), 323 284, 323 sodomy and genital-to-anal contact without penetration, 321 Sexual maturity rating (SMR), 75, 317 Sexual assault Sexual penetration crimes, 389–391 evidence collection kit, 174–175 Sexual promiscuity, 32 and Locard principle, 140 Sexual trauma, 1–2 nurse clinician, 263 to allostatic loading, model of, 36f perpetrators, 389 behavioral consequences, 27 suspect forensic examination, 336 eating disorders, 32 Sexual assault evidence collection kit (SAK), 283 employment, financial, and residential instability, 33 Sexual assault examination kits (SAKs), 383 risky sexual behaviors, 32 Sexual assault examiner (SAE), 90 self -harm and suicide, 33–34 Sexual assault forensic examiner (SAFE), 2, 90, 250, 256, sleep disorders, 32–33 263, 266 substance abuses, 27–32 legal issues, prosecutor’s perspective, 388, 393–395 troubled relationships, 33 prehospital care providers, EMS role, 356, 360 behavior disorders, 28t–31t suspect examination, 337 cardiovascular function, 20 Sexual assault nurse examiner (SANE), 2, 101, 185, 192, 261, arrhythmias, 20 263, 266, 283 endocrine function, 17–18 legal issues, prosecutor’s perspective, 388, 393, 395, 402 gastrointestinal function, 16–17 prehospital care providers, EMS role, 356, 360 history, 3–8 programs, evaluation, 283–284 immune and hematologic function, 19 care of victim, 290–291 impaired auditory and visual function, 16 community effectiveness, 290 liver function, 17 emergency department setting, 284–285 musculoskeletal function, 16 forensic effectiveness, 288 neurologic and cognitive function, 14–15 legal effectiveness, 289 pain perception, 15–16 medical effectiveness, 287–288 physical disorders with, 9t–13t psychological effectiveness, 286–287 physical health consequences, 8–14 sexual assault nurse examiner, 285–286 premature mortality, 20 responsibilities, 269 prevention, 38–39 discharge, 270 psychological consequences mandatory reporting, 269 anxiety disorders, 21–25 non-report sexual assault examinations, 269 bipolar disorder, 27 report, 270 depression, 26 training disassociation, 26 education components, 271t emotional function, 20 education trends, 272 personality disorder, 27 IAFN Certification, 270–271 phobia and panic disorders, 25–26 SANE education trends, 272 posttraumatic stress disorder, 25 state-level certification, 270 schizophrenia and psychoses, 27 Sexual assault response team (SART), 2, 174, 250, 256, 261, somatization, 26–27 263, 272–275, 290 psychological disorders, 22t–24t law enforcement issues, 364 respiratory function, 19–20 prehospital care providers, EMS role, 356, 360 state of the science, 34 Sexual contact crimes, 391 sexually transmitted infections, 19 Sexual dysfunction, 18 urinary function, 17 Sexual exposure crimes, 389, 391 victims, care of, 34–35, 36f Sexual harassment, 2
423 Sexual Assault: Victimization Across the Life Span, Second Edition, Volume 1: Investigation, Diagnosis, and the Multidisciplinary Team
Sexual violence, 3, 250 Supernumerary nipples (polythelia), 70 forms, 252 Support services, 255 international systems response to, 249–250 Survivor, 3, 250 challenges, 256 Suspected child abuse, normal and nonspecific findings in, cooperation and collaboration, 250–251 203t–204t current evidence-based state of the science, 254–255 Suspect forensic examination DNA databases, 251 The American Board of Forensic Odontologists (ABFO) global perspective, 252 Ruler No. 2, 336 consequences, 252–253 deoxyribonucleic acid (DNA), 336 incidence, 252 epithelial cells, 336, 349 societal costs, 253 evidence collection kit, components of, 338 models of victim services, 253 legal considerations, 337–338 advocate- or community-based services, 254 patient, 336 hospital-based or hospital-affiliated services, 253 procedure medicolegal-based services, 253–254 alternate light source (ALS), 345 public policy, 251 blood and urine samples, 350, 350f Shigella, 214 buttock, perineum, anal, and rectal examination, 349, 349f Shigella vaginitis, 210 clothes collection, 340 Short tandem repeat (STR) profiles, 160 consent, 338 Single-fetus pregnancies, 18 facial hair combing or swabbing, 346, 346f Skene’s duct cysts, 61 fingernails, 347–348, 347f Sleep disorders, 32–33 forensic nurse, 338 Sleeping pills, 31 general assessment, 340, 341f–344f Smegma, 57 genital examination, 348 Societal costs, 253 hands, 346–347, 347f Sodomy and genital-to-anal contact without penetration, 321 head hair combing and collection, 345, 345f Somatization, 26–27 oral, 346, 346f Sperm and epithelial cell nuclei, 145f penile and scrotal swabbing, 349, 349f Spermatocele, 74 photographs, 339, 339f Spermatozoa, 139–140, 145, 147–150 pubic hair, 348–349, 348f Sphincter ani, 55 swab collection, 339 Squamous epithelium, 71 reasons for, 336–337 Standard reference samples, suspect examination, 336–337 report, 351a–352a Staphylococcus aureus, 214 search warrant or court order, 336–338, 348, 349 Starvation, 74 sexual assault suspect, 336 Statherin, 160 standard sample, or reference sample, 336 Statute of limitations, 250, 389 Swab(s) Stevens-Johnson syndrome, 221 collection, suspect forensic examination, 339 STIs. See Sexually transmitted infections (STIs) and smears, 185–187 Straddle injuries, 209, 210f Swabbings, 181, 186f Streptococcus pneumoniae, 214 of buccal cavity, 180f Subjective documentation, 360 Subpoena, 234 Substance abuse, 27–32 T Tamm-Horsfall (THP) glycoprotein, 153 Superficial fissures, 79 Tanner staging system, 75 Superficial notches, 204, 207 of maturity, 75t–76t Supernumerary breasts (polymastia), 70 Teichmann test
424 Index
for blood, 142 U and Takayama tests, 151 Ulcers, 212 Testes, 55 Uncircumcised male anatomy, 318f Testicular failure, 74 Unconsciousness, 115 Testifying in court, verbal evidence, 229–231, 241–243 United Nations Office on Drugs and Crime (UNODC), 251 court system, 231 Unreported kits, 394 expert witness, 232 Unwanted pregnancy, 253 nurse as expert witness, 233–234 Ureterocele, 221 participants, 231–232 Urethra, 55 preparing for trial, 234 Urethral bleeding, 221 trial proceedings, 234–235 Urethral caruncle, 61 deposition, 235 Urethral duplication, atresia, fistula, parameatal cysts, or active listening, 236–238 megalourethra, 58 after, 241 Urethral meatal stenosis, 57 duces tecum, 235–236 Urethral prolapse, 61f giving a deposition, 236 Urethritis, 221 goal of questioning, 239 Uric acid crystals, 57 identifying poorly formed questions, 238–239 Urinary norepinephrine, 25 subpoenas, 235 Urinary tract infections (UTI), 253 testing case facts and field expertise, 240 Urine, 156 testing knowledge sources, 241 and fecal matter, 152–153 direct examination, 243–244 Urobilin, 153 ten commandments of, 242 Urogenital sinus, 62 Testosterone, 55, 56 anomalies, 79 synthesis, 74 Urologic conditions, 221–222 Th1, 19 Uromodulin for urine, 157 Th2, 19 Uterine anomalies and absence of cervix, 61 Thelarche, 70 Uterus, 55, 62 Toxicology, 187, 187f Trace evidence, 170, 176 Tranquilizers, 31 V Vagina, 55, 310 Transhymenal orifice diameter by the separation technique (THODST), 68 Vaginal agenesis, 60 Transient evidence, 170, 177, 177f Vaginal atresia, 60 Transporting victims to hospitals, 360–361 Vaginal discharge, 214 Trauma, 3 Vaginal duplication, 60 anogenital, 209 Vaginal fluid, 153–154, 156, 160 extragenital, 321 Vaginal foreign body mimicking infection, 220 genital, 312, 316 Vaginal mucosa, 61 nonabusive, 209–211 Vaginal penetration, 318, 319–320 psychological and physical, 381 Vaginal prolapse or procidentia, 60 and victim reactions, 381–382 Vaginal rugae, 66 See also Sexual trauma Vaginal septum, 60f Triple-quadrupole mass spectrometer performing multiple Vaginal vestibule, 308, 310–311 reaction monitoring (QQQ-MRM), 158 Vaginitis, 221 seminal fluid identification, 158f Varicocele, 74 Troubled relationships, 33 Vas deferens, 55 Turner syndrome, 68 Vehicle identification number (VIN), 368
425 Sexual Assault: Victimization Across the Life Span, Second Edition, Volume 1: Investigation, Diagnosis, and the Multidisciplinary Team
Venous congestion, 208 W Verbal evidence, testifying in court, 229–231, 241–243 Wood’s lamp, 147 court system, 231 World Health Organization (WHO), 3, 251 expert witness, 232 Written protocol, 254 nurse as expert witness, 233–234 participants, 231–232 Y preparing for trial, 234 Yersinia entercolitica, 214 trial proceedings, 234–235 deposition, 235 Z active listening, 236–238 Zoster infection, 74 after, 241 duces tecum, 235–236 giving a deposition, 236 goal of questioning, 239 identifying poorly formed questions, 238–239 subpoenas, 235 testing case facts and field expertise, 240 testing knowledge sources, 241 direct examination, 243–244 cross-examination, 244–245 goals of questioning, 245–246 Vertical prosecution, 399 Vestibular bands, 204, 205f Victim contact, police role, 379–381 deoxyribonucleic acid (DNA) analysis, 337 psychological and physical trauma, 381 psychology, 356–357 rights, legal issues, 390 transporting victims to hospitals, 360–361 trauma and reactions, 381–382 Victim-centered care, 111, 117 Victim-centered response, 378 Videocolposcopy, 300 VIN. See Vehicle identification number (VIN) Vinyl polysiloxane (VPS), 133 Violence, 33 Violence Against Women Act (VAWA), 3, 263, 389, 394 Voir dire, 401–402 Voluntary self-inflicted bite marks, 122 Vulnerable groups, 3 Vulva, 55, 310 Vulvar coitus, 313, 319 Vulvar hematomas, 211 Vulvovaginitis, 214–215
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