Sexual Assault Quick Reference

Second Edition

For Health Care, Social Service, and Law Enforcement Professionals

STM Learning, Inc. Leading Publisher of Scientific, Technical, and Medical Educational Resources Saint Louis www.stmlearning.com i Saint Louis www.stmlearning.com Our Mission

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A portion of our profits is contributed to nonprofit organizations dedicated to the prevention of child abuse and the care of victims of abuse and other children and family charities. Contributors to the Second Edition Eileen M. Alexy, Imelda Buncab, BA PhD, RN, APN, PMHCNS-BC Social Change Agent and Consultant Associate Professor Sherman Oaks, California School of Nursing, Health, and Exercise Science Kelley Catron, DNP, WHNP-BC Department of Nursing Instructor The College of New Jersey Family, Child Health and Caregiver Ewing, New Jersey Department University of Alabama at Birmingham Eileen M. Allen, School of Nursing MSN, RN, FN-CSA, SANE-A, SANE-P Birmingham, Alabama Coordinator Monmouth County SANE/SART Paul Thomas Clements, Program PhD, RN, DF-IAFN Freehold, New Jersey Associate Clinical Professor Adjunct Faculty Coordinator – Contemporary Trends in Monmouth University Forensic Health Care Certificate Online West Long Branch, New Jersey Drexel University College of Nursing and Health Professions Mary Katherine Dunne Atkins, Philadelphia, Pennsylvania MSN, NP-C Certified Registered Nurse Practitioner Elizabeth Dowdell, PhD, MS, RN Epilepsy Center/Department of Neurology Professor Registered Nurse Villanova University College of Nursing Surgical Intensive Care Unit Villanova, Pennsylvania University of Alabama Birmingham Birmingham, Alabama Donna Campbell Dunn, Olivia S. Ashley, DrPH PhD, CNM, FNP-BC Senior Public Health Scientist Assistant Professor Director, Risk Behavior and Family Continuing Care Research Program University of Alabama at Birmingham Associate Director, Global Gender Center School of Nursing Behavioral Health and Criminal Justice Birmingham, Alabama Division RTI International Diana K. Faugno, MSN, RN, CPN, Research Triangle Park, North Carolina SANE-A, SANE-P, FAAFS, DF-IAFN Forensic Nurse Examiner Natalie Baker, DNP, ANP-BC, GNP-BC Barbara Sinatra Children’s Center Assistant Professor Eisenhower Medical Center Acute, Chronic, and Continuing Care Emergency Room University of Alabama at Birmingham, Rancho Mirage, California School of Nursing Birmingham, Alabama

v Contributors to the Second Edition

Annie Heirendt, LCSW Memorial Hospital, University of Colo- Los Angeles, California rado Health Colorado Springs, Colorado Aimee Chism Holland, DNP, WHNP-BC, FNP-C Patricia M. Speck, DNSc, APN, FNP- Assistant Professor BC, DF-IAFN, FAAFS, FAAN University of Alabama at Birmingham Associate Professor School of Nursing University of Alabama at Birmingham Birmingham, Alabama School of Nursing Program Director for Global Affairs Megan Lechner, Department of Family, Community, & MSN, RN, CNS, SANE-P, SANE-A Health Systems Forensic Nurse Examiner, Birmingham, Alabama Clinical Team Lead Memorial Hospital, Mary J. Spencer, MD University of Colorado Clinical Professor of Pediatrics Adjunct Professor University of California, San Diego University of Colorado School of Medicine at Colorado Springs Medical Director Colorado Springs, Colorado Child Abuse Prevention and SART Palomar Pomerado Health Annie McCartney, MSN, WHNP-BC San Diego, California Instructor Adult/Acute Health, Amy Thompson, MD Chronic Care and Foundations Assistant Professor of Medicine University of Alabama at Birmingham Department of Pediatrics Birmingham, Alabama Jefferson Medical College Philadelphia, Pennsylvania CDR Barbara Mullen (FNP), NC, USN Attending Physician Family Nurse Practitioner Department of Emergency Medicine United States Naval Academy Alfred I duPont Hospital for Children/ Annapolis, Maryland Nemours Wilmington, Delaware Tawnne O’Connor, RN, BSN Sexual Assault Nurse Examiner Ashton Tureaud Strachan, Patient Care Coordinator DNP, CRNP, FNP-C Naval Medical Center San Diego Family Nurse Practitioner/Nurse Manager San Diego, California Student Health and Wellness Clinic University of Alabama at Birmingham Jennifer Pierce-Weeks, Birmingham, Alamabama RN, SANE-P, SANE-A Project Director Victor I. Vieth, JD International Association of Forensic Nurses Senior Director Elkridge, Maryland Gundersen National Child Protection Forensic Nurse Examiner Training Center Emergency Department Winona, Minnesota vi Contributors to the First Edition Joyce A. Adams, MD Janice B. Asher, MD Clinical Professor of Pediatrics Assistant Clinical Professor Division of General Academic Pediatrics Obstetrics and Gynecology and Adolescent Medicine University of Pennsylvania Medical Center University of California, San Diego Director Medical Center Women’s Health Division of Student San Diego, California Health Service University of Pennsylvania Randell Alexander, MD, PhD, FAAP Philadelphia, Pennsylvania Associate Professor Clinical Pediatrics Tracy Bahm, JD Morehouse School of Medicine Senior Attorney Forensic Pediatrician Violence Against Women Program Department of Pediatrics American Prosecutors Research Institute Morehouse School of Medicine (APRI) Atlanta, Georgia Alexandria, Virginia

Eileen Allen, RN, BN, DABFN Kathy Bell, RN SANE Program Coordinator Forensic Nurse Examiner Monmouth County Prosecutor’s Office Tulsa Police Department Freehold, New Jersey Tulsa, Oklahoma

Sarah Anderson, RN, MSN Patrick E. Besant-Matthews, MD University of Virginia Forensic Pathology and Forensic Medicine Department of Emergency Medicine Legal and Law Enforcement Consultations (Registered Nurse) Private Practice School of Nursing (Doctoral Student) Dallas, Texas Charlottesville, Virginia Sandra L. Bloom, MD Joanne Archambault CEO, Community Works Training Director Philadelphia, Pennsylvania Sexual Assault Training and Investiga- tions (SATI, Inc.) Duncan T. Brown, JD Retired Sergeant Staff Attorney San Diego Police Department National Center for Prosecution Sex Crimes Unit of Child Abuse American Prosecutors Research Institute (APRI) Alexandria, Virginia

vii Contributors to the First Edition

Mary-Ann Burkhart, JD Sue Dickinson, Senior Attorney RN, BSN, PHN, CEDN, SANE-A National Center for Prosecution Forensic Nurse Examiner of Child Abuse Palomar Pomerado Health American Prosecutors Research Institute Escondido, California (APRI) Alexandria, Virginia Colette M. Eastman, DO Obstetrics, Gynecology, and Reproduc- Susan Chasson, MSN, CNM, JD tive Medicine Lecturer Physician Consultant/Instructor, Sexual College of Nursing Assault Response Team Brigham Young University Poway, California Provo, Utah Thomas Ervin, RNC, FN, BSc† Michael Clark, MSN, CRNP Reception and Release Coordinator Nurse Practitioner California State Prison at Corcoran Department of Emergency Medicine Department of Corrections Hospital of the University of Pennsylvania State of California Clinical Lecturer University of Pennsylvania School of Diana K. Faugno, Nursing RN, BSN, CPN, FAAFS, SANE-A Philadelphia, Pennsylvania District Director Pediatrics/Nicu Sharon W. Cooper, MD, FAAP Forensic Health Service Adjunct Associate Professor of Pediatrics Palomar Pomerado Health University of North Carolina School of Escondido, California Medicine Chapel Hill, North Carolina Anne B. Finigan, RN, MScN, ACNP Clinical Assistant Professor of Pediatrics Forensic Clinical Nurse Specialist/Nurse Uniformed Services University of Health Practitioner Sciences Regional Sexual Assault and Domestic Bethesda, Maryland Violence Treatment Centre Chief St. Joseph’s Health Care London Developmental Pediatric Service London, Ontario Womack Army Medical Center Canada Fort Bragg, North Carolina Martin A. Finkel, DO, FACOP, FAAP Elizabeth M. Datner, MD Professor of Pediatrics Assistant Professor Medical Director University of Pennsylvania School of Center for Children’s Support Medicine School of Osteopathic Medicine Department of Emergency Medicine University of Medicine and Dentistry of Assistant Professor of Emergency Medi- New Jersey cine in Pediatrics Stratford, New Jersey Children’s Hospital of Philadelphia Philadelphia, Pennsylvania viii Contributors to the First Edition

Marla J. Friedman, MD Caren Harp, JD Fellow, Pediatric Emergency Medicine Senior Attorney/ Director Emergency Medicine National Juvenile Justice Prosecution Center Alfred I. duPont Hospital for Children American Prosecutors Research Institute Wilmington, Delaware (APRI) Alexandria, Virginia Donna Gaffney, RN, DNSc, FAAN Associate Professor, Acute Care Nurse William C. Holmes, MD, MSCE Practitioner Program Assistant Professor of Medicine and College of Nursing Epidemiology Seton Hall University Philadelphia Veterans Affairs Medical Center South Orange, New Jersey Center for Clinical Epidemiology and Biostatistics Ann E. Gaulin, MS, MFT University of Pennsylvania School of Director of Counseling Services Medicine Women Organized Against Rape Philadelphia, Pennsylvania Philadelphia, Pennsylvania Jeffrey R. Jaeger, MD Angelo P. Giardino, MD, PhD Assistant Professor of Medicine Associate Chair – Pediatrics University of Pennsylvania Health System Associate Physician-in-Chief Clinical Faculty, Institute for Safe Families St. Christopher’s Hospital for Children Philadelphia, Pennsylvania Associate Professor in Pediatrics Drexel University College of Medicine Susan Bieber Kennedy, RN, JD Philadelphia, Pennsylvania Senior Attorney Violence Against Women Program Eileen R. Giardino, PhD, RN, CRNP American Prosecutors Research Institute Associate Professor (APRI) LaSalle University, School of Nursing Alexandria, Virginia Nurse Practitioner LaSalle University, Student Health Lisa Kreeger, JD Center Senior Attorney Philadelphia, Pennsylvania Violence Against Women Program Manager DNA Forensics Program Manager Barbara W. Girardin, RN, PhD American Prosecutors Research Institute Forensic Health Care (APRI) Palomar Pomerado Health Alexandria, Virginia Escondido, California Susan Kreston, JD Holly M. Harner, Deputy Director CRNP, PhD, MPH, SANE National Center for Prosecution of Child Assistant Professor Abuse William F. Connell School of Nursing American Prosecutors Research Institute Boston College (APRI) Chestnut Hill, Massachusetts Alexandria Virginia

ix Contributors to the First Edition

Linda E. Ledray, Jeanne Marrazzo, MD, MPH RN, PhD, SANE-A, FAAN Assistant Professor Director Department of Medicine Sexual Assault Resource Service Division of Allergy and Infectious Diseases Hennepin County Medical Center University of Washington Minneapolis, Minnesota Seattle, Washington Medical Director Carolyn J. Levitt, MD Seattle STD/HIV Prevention Training Assistant Professor of Pediatrics Center Department of Pediatrics Seattle, Washington University of Minnesota Director Claire Nelli, RN, SANE-A Midwest Children’s Resource Center Manager—SART Department Children’s Hospitals and Clinics Villa View Community Hospital St. Paul, Minnesota San Diego, California

Patsy Rauton Lightle Patrick O’Donnell, PhD Supervisory Special Agent Supervising Criminalist, DNA Laboratory Lieutenant Department of Child Fatalities San Diego Police Department South Carolina Law Enforcement Division San Diego, California Columbia, South Carolina Jason Payne James, LLM, FRCS Judith A. Linden, MD, FACEP, SANE (Edin & Eng), DFM, RNutr Assistant Professor Forensic Physician Emergency Medicine Forensic Medical Examiner - Metropolitan Boston University School of Medicine Police Service and City of London Police Associate Residency Director Director - Forensic Healthcare Services, Ltd. Boston University School of Medicine Editor-in-Chief, Journal of Clinical Boston Medical Center Forensic Medicine Boston, Massachusetts London, England United Kingdom John Loiselle, MD Associate Professor of Pediatrics Christine M. Peterson, MD Jefferson Medical College Director of Gynecology Assistant Director, Emergency Medicine Department of Student Health Alfred I. duPont Hospital for Children Assistant Professor of Clinical Obstetrics Wilmington, Delaware and Gynecolgy University of Virginia School of Medicine Kathi Makoroff, MD Charlottesville, Virginia Mayerson Center for Safe and Healthy Children Hannah Ufberg Rabinowitz, MSN, Cincinnati Children’s Hospital Medical ARNP, FNA, NCGNP Center Clinical Education Cincinnati, Ohio Aventura Hospital Aventura, Florida

x Contributors to the First Edition

William J. Reed, MD, FAAP Rena Rovere, MS, FNP Assistant Professor of Pediatrics Sexual Assault Program Director Texas A&M College of Medicine Clinical Nurse Specialist Behavioral and Adolescent Medicine Department of Emergency Medicine Driscoll Children’s Hospital Albany Medical Center Corpus Christi, Texas Albany, New York

Iris Reyes, MD, FACEP Bruce D. Rubin, MD Assistant Professor Clinical Instructor Emergency Medicine Department of Emergency Medicine Hospital of the University of Pennsylvania Hospital of the University of Pennsylvania Assistant Medical Director Philadelphia, Pennsylvania Emergency Medicine Hospital of the University of Pennsylvania Maureen S. Rush, MS Philadelphia, Pennsylvania Vice President for Public Safety University of Pennsylvania Dawn Rice, RN, BSN, FNE Division of Public Safety Executive Director Philadelphia, Pennsylvania Fort Wayne Sexual Assault Treatment Center Charles J. Schubert, MD President Associate Professor of Pediatrics Indiana Chapter of the IAFN Division of Emergency Medicine Fort Wayne, Indiana Cincinnati Children’s Hospital Medical Center Laura L. Rogers, JD Cincinnati, Ohio Senior Attorney National Center for Prosecution of Child Diana Schunn, RN, BSN, SANE-A Abuse SANE/SART Manager American Prosecutors Research Institute Via Christi Regional Medical Center (APRI) Wichita, Kansas Alexandria, Virginia Margot Schwartz, MD Mimi Rose, JD Virginia Mason Medical Center Chief Assistant District Attorney Infectious Diseases Section Family Violence and Sexual Assault Unit Seattle, Washington Philadelphia District Attorney Office Clinical Instructor Philadelphia, Pennsylvania Department of Medicine University of Washington Pamela Ross, MD Seattle, Washington Assistant Professor of Emergency Medicine & Pediatrics Deborah K. Scott, University of Virginia Health System RN-C, BSN, ARNP, FNS Charlottesville, Virginia Child Protection Team Howard Phillips Center for Children and Families Orlando, Florida

xi Contributors to the First Edition

Philip Scribano, DO, MSCE Jeanne L. Stanley, PhD Assistant Professor Executive Director of Academic Services Pediatrics and Emergency Medicine Graduate School of Education University of Connecticut School of University of Pennsylvania Medicine Philadelphia, Pennsylvania Director, Child Protection Program Connecticut Children’s Medical Center Cari Michele Steele, JD Hartford, Connecticut Staff Attorney National Center for Prosecution Christina Shaw, JD of Child Abuse Staff Attorney American Prosecutors Research Institute National Center for Prosecution (APRI) of Child Abuse Alexandria, Virginia American Prosecutors Research Institute (APRI) Jacqueline M. Sugarman, MD Alexandria, Virginia Assistant Professor of Pediatrics Department of Pediatrics Patricia M. Speck, APRN, MSN, BC College of Medicine Coordinator of Nursing Services University of Kentucky and Interim Manager Lexington, Kentucky City of Memphis Sexual Assault Resource Center Kathryn M. Turman Division of Public Services Program Director and Neighborhoods Office of Victim Assistance Memphis, Tennessee Federal Bureau of Investigation Washington, DC Mary J. Spencer, MD Clinical Professor of Pediatrics Victor I. Vieth, JD University of California San Diego Director School of Medicine National Center for Prosecution Medical Director of Child Abuse Child Abuse Prevention and American Prosecutors Research Institute Sexual Assault Response Team (APRI) Palomar Pomerado Health Alexandria, Virginia Escondido, California Malinda Waddell, RN, MN, FNP Norman D. Sperber, DDS Director-Forensic Nurse Specialists Chief Forensic Dentist, San Diego Long Beach, California and Imperial County Diplomate, American Board of Forensic J.M. Whitworth, MD Odontology Professor of Pediatrics Distinguished Fellow, American Academy University of Florida of Forensic Sciences State Medical Director San Diego, California Child Protection Team Program Children’s Medical Services Department of Health State of Florida xii Foreword to the Second Edition Sexual assault covers a broad spectrum of unwanted sexual contact. This includes unwanted touching; forced physical contact; and forced viewing of, or involvement in, pornography. The survivor population is incredibly diverse, including both women and men from a variety of cultures, eth- nicities, and age groups. Sexual assault may physically injure survivors and it may also exact profound, long-term emotional tolls from both primary survivors and secondary survivors, ie, in their family and friends. This problem is compounded by the low percentage of survivors who report incidents of sexual assault and, as a result, the low percentage who receives the qualified help that is so crucial to their recovery—help that should include a coordinated response from medical professionals, trained sexual assault nurse examiners, advocates, and law enforcement. Sexual Assault Quick Reference, Second Edition is a detailed reference guide that covers a range of common and uncommon types of sexual assault, offers essential guidance and recommended treatments based on research and extensive treatment histories, and provides procedural guidelines for patient-practitioner interaction to promote best possible outcomes. It is a comprehensive, reference tool that should be considered an essential re- source for professionals and volunteers serving in the sexual assault com- munity of practice. Readers from across the full spectrum of sexual assault responders will benefit from the knowledge contained in this book. After reading Sexual Assault Quick Reference, Second Edition, sexual assault sup- port service providers will be able to improve and standardize their ability to deliver consistent, high-quality care in a variety of sexual assault cases and for the survivors of those incidents. Elisa Covarrubias Director of Sexual Assault and Advocacy Programs Marietta, GA

Sarah Pederson, BSN, RN, SANE Sexual Assault Nurse Examiner Coordinator Marietta, GA

xv 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 be- havior was recently added in response to the recognition that pharmacologic agents can be used to make the victim more malleable. When sexual activity occurs between a significantly older persona 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 perpetrator gradually escalates the type of sexual contact with the child and often does not use the force implied in the term sexual assault. But it is assault, both physically and emotionally, 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 a mere fraction of the true incidence. The financial costs of sexual assault are enormous; intangible costs, such as emotional suffering and risk of death from being victimized, are beyond measure- ment. Short-term and long-term consequences reach far into all emotional and physical aspects of a victim’s life. Trained professionals work every day to combat sexual assault in all its forms as well as the adverse aftereffects. This book offers information for all who deal with sexual assault—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. This book seeks to provide this information in a most accessible manner for professionals needing an immediate resource; it will fill a need in many avenues 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, the Quarterly Child Abuse Medical Update

xvii Foreword to the First Edition Health care, social service, and law enforcement professionals have the unique opportunity to make a difference in how victims of sexual assault will incorporate that event into the rest of their lives. The well-prepared professional is aware of the patient’s needs and sensitive to the victim’s response to the examination process. This attentiveness will go a long way in beginning the emotional healing process necessary to integrate the events. Giving control back to the victim of rape is therapeutic and should be a priority throughout the examination. The primary purpose of the sexual assault examination by the health care professional is to provide for medical diagnosis and treatment. The exam- iner needs to keep in mind that observations may be the result of normal development, a result of trauma caused by accident or abuse, or the result of a disease condition. Treatment may be of a clinical, psychological, or emotional nature. The evidence-collection portion of the examination assists in linking the victim, the suspect, the crime scene, and the evidence. Documentation of this portion of the examination is just as important as documenting the history and physical assessment. This text provides easy-to-access information outline forensic, biologic, and technologic evidence collection within the discussion of the many unique situations in which a sexual assault may occur. Necessary for any professional who deals with sexual assault, this quick ref- erence provides a base of details essential to accomplish a thorough medical forensic examination. Kathy Bell, RN Forensic Nurse Examiner Tulsa Police Department Tulsa, Oklahoma

xix Preface to the Second Edition The impact of sexual assault and abuse is far-reaching and observed across so- cial strata in communities throughout the world. Survivors are made to endure not only the injuries immediately resulting from offenses committed against them but also long-term physical, emotional, and psychological disorders that can, in some cases, last a lifetime. It is, therefore, the responsibility of those charged with caring for and representing the interests of the survivors of sexual assault to both safeguard them in the immediate aftermath of their encounters with criminal violence and, ideally, help guide them toward a path of resilient recovery, long after the end of initial treatments and investigations. The intent of Sexual Assault Quick Reference is to support medical, social service, and legal professionals in the delivery of responsive and compassionate caregiving as well as investigative techniques tailored to the unique needs of sexual assault survivors. It ensures that readers always have an easily accessible reference on hand for a variety of topics relevant to cases of sexual assault. In recognition of the field’s continual evolution, this new Second Edition revision has up-to-date standards and contemporary best practices in the medical forensic evaluation of patients across the life span, identifying and documenting physical injury, appropriately documenting and reporting cases of sexual violence, recognizing and treating sexually transmitted infections, and providing psychological and social support to survivors. Effective response to sexual assault, as well as the best possible outcomes for survivors, depends upon the cooperative efforts of informed and dedicated professionals across disciplines, be they physicians, nurses, mental health prac- titioners, emergency responders, law enforcement officials, attorneys, or social service workers. This book is possible because of the commitment of nearly 100 such professionals and their combined expertise. We are happy now to offer it to you, and we sincerely hope that it will be of value and inform your efforts to mitigate the impact of sexual violence in all its forms and in the inter- est of the survivors seeking your care. Diana K. Faugno, MSN, RN, CPN, SANE-A, SANE-P, FAAFS, DF-IAFN Patricia M. Speck, DNSc, APN, FNP-BC, DF-IAFN, FAAFS, FAAN Mary J. Spencer, MD Angelo P. Giardino, MD, PhD

xxi Preface to the First Edition Sex crimes are now recognized as the precipitating event for various physi- cal, emotional, and psychological disorders. Individuals, families, and the society as a whole suffer. Professionals are charged with working to identify and document the presence of physical injury to corroborate the victim’s history, which contributes to the investigation of possible sexual abuse and assault and holds offenders accountable for their crime. Aids in this process include photographic, colposcopic, video, and narrative documentation, and the quality of these media continues to improve. Secure computer pro- grams are being used to transmit photographs so that various professionals can consult on injuries. Research investigating assault injuries continues to support the position that the presence of injury does not prove assault, nor does the absence of injury prove consent. The interdisciplinary sexual assault response team (SART) approach, in which an expert nurse exam- iner or physician, a sex crimes detective, an advocate, and an experienced, specialized prosecutor work in tandem, has streamlined the process for the victim. Emotional care offered from the time of the examination has softened the impact of the process and helped the victim toward recovery. More efficient and better funded DNA profiling at the local, state, and national levels allows for more timely identification of offenders. In this text, we see the problem of sexual assault and abuse through the eyes of many professionals: physicians, paramedics, law enforcement personnel, the judicial system, social workers, and people who work with children. The knowledge shared by these concerned and caring individuals supplies the power to intervene. This book offers current, accurate, and specific data concerning the problem of sexual assault in an easy-to-access format. With this information, we become empowered participants whose effec- tive interventions help prevent sexual assault as well as care for its victims. Angelo P. Giardino, MD, PhD Elizabeth M. Datner, MD Janice B. Asher, MD Barbara W. Girardin, RN, PhD Diana K. Faugno, RN, BSN, CNP, FAAFS, SANE-A Mary J. Spencer, MD

xxiii Reviews Sexual Assault Quick Reference, variants and disease processes that Second Edition contains easy-to-read, mimic injuries seen in sexual abuse. yet comprehensive, material related to I recommend this textbook for course caring for the sexual assault survivor. coordinators when developing SANE-A/ The many professions that make up the SANE-P course curricula as it covers a multidisciplinary team caring for these wide variety of subjects that should be victims, including physicians, nurses, taught in any SANE curriculum. The emergency responders, social service per- Quick Reference is also an excellent sonnel, attorneys, and law enforcement, guide to SANE program coordinators will find that this reference includes to reference when developing polices, accurate, up-to-date information and protocols, or guidelines for their institu- guidelines to assist in the care of these tions. All health care personnel would individuals. This pocket reference benefit from this textbook as it provides captures the content of the many areas of the most up-to-date material when knowledge necessary to care for victims working with victims of sexual violence. of sexual assault and has been written Barbra Bachmeir, JD, MSN, NP-C by a team of leaders with insurmount- Nurse Practitioner/Forensic Nurse able knowledge and experience in this Examiner field. This text is recommended with the Emergency Department highest regards. IU Health-Methodist Hospital Jessica L. Ahmann, Indianapolis, Indiana DNP, APRN, FNP-BC Family Nurse Practitioner This textbook would be a valuable Children’s Advocacy Center reference for any professional or agency Sanford that provides services to sexual assault Bismarck, North Dakota or sexual abuse survivors of any age. The chapters are written by experts Sexual Assault Quick Reference is a in forensic medicine, forensic nursing, must-have reference for new SANEs forensic DNA analysis, social work, and to assist in their assessments, nursing other specialties relevant to working diagnoses, and documentation. Chapter with victims of sexual assault or sexual 5, “Differential Diagnosis,” is compre- exploitation. Chapters include the basic hensive in identifying common normal legal definitions of sexual assault, sexual

xxv Reviews

battery, and sexual exploitation; dif- “Sexual Assault Response in the United ferentiating abuse/assault injuries from States Military,” is a practical read for nonabuse/nonassault injuries or disease those unfamiliar with the military and process in a victim of any age; how to how its legal system works. Chapter 20, form and manage a multidisciplinary “Strangulation in Living Patients,” is team; what to include in the forensic nothing short of amazing with its color medical report and who will view that photos and precise breakdown of patient report; the chain of custody, combined assessment, forensic photography, and DNA index system, DNA evidence, signs and symptoms of strangulation and collecting reference samples; sexual that require further investigation and assault by an acquaintance or inti- evaluation. I highly recommend this mate partner and the heavy emotional second edition as a go-to resource for burden it places on the victim; and professionals who respond to and care issues unique to elder victims living in for victims of sexual assault. residential care facilities or when in- Cynthia T. Ferguson, PhD, MSN, home caregivers are suspects. MPH, MFA, RN, CNM, AFN-BC, Thomas Collins, MA, ADN D-ABMDI (Certificate in Forensic Nursing), AAS CDR (ret.) United States Navy (Forensic Technology) Clinical Forensics Program Consultant Instructor, UCR Extension Ferguson Forensics Certificate Program in Forensic Nursing Palmyra, Virginia University of California at Riverside Riverside, California Clinical Nurse III University of California, San Diego Health System San Diego, California

The second edition of Sexual As- sault Quick Reference is an excellent resource for all health care providers who see victims of sexual violence. In particular, Chapters 15-21 provide a wealth of new information on topics essential to victim care. Chapter 18,

xxvi Contents in Brief

Chapter 1: Principles of Sexual Assault at Any Age 1

Chapter 2: Anogenital Anatomy 29

Chapter 3: Physical Evaluation of Children 59

Chapter 4: Forensic Evaluation of Children 81

Chapter 5: Differential Diagnosis 95

Chapter 6: Evaluations in Special Situations 111

Chapter 7: Multidisciplinary Teamwork Issues 141

Chapter 8: Documentation and Reporting 157

Chapter 9: Physical Evaluation of Adolescents and Adults 171

Chapter 10: Forensic Evaluation of Adolescents and Adults 187

Chapter 11: Sexually Transmitted Infections 209

Chapter 12: Pregnancy 229

Chapter 13: Acquaintance and Intimate Partner Rape 241

Chapter 14: Special Settings 263

Chapter 15: Psychological and Social Supports 283

Chapter 16: Caregiver Issues 313

Chapter 17: Legal Issues, Investigation, and Prosecution 337

Chapter 18: Sexual Assault Response in the United States Military 389

Chapter 19: Human Trafficking 399

Chapter 20: Strangulation in Living Patients 421

Chapter 21: Risks to Children and Adolescents on the Internet 433

Photographic Appendix 445

Index 497

xxvii 1 Chapter

Principles of Sexual Assault at Any Age Amy Thompson, MD* Marla J. Friedman, DO Judith A. Linden, MD, FACEP, SANE John Loiselle, MD Janet S. Young, MD

Child Sexual Abuse Child sexual abuse is not a new problem but has only been accepted as a bona fide entity that deserves professional attention since the 1970s. Its definition is subject to interpretation on multiple levels. Institutional, societal, medical, and legal terminology all differ in either definition or emphasis. A broad range of developmentally inappropriate sexual behaviors is included, covering both contact and noncontact activities. The Child Abuse Prevention and Treatment Act (CAPTA) of 1974 provided a federal legal standard that all states were mandated to follow to be eligible for funds for child abuse programs. This act defined sexual abuse as “the employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct.” Principles that mark most legal definitions include the following: ——A child is defined as a person under age 18 years, with some exceptions. ——Most statutes emphasize the discrepancy between the perpetrator’s and victim’s ages.

*Revised Chapter 1 for the second edition.

1 Sexual Assault Quick Reference

——The developmental level of the child is considered. ——Laws generally distinguish who is considered a caretaker or guardian for the child. ——When the caretaker is involved in the abuse, involvement of the local child protective services (CPS) agency and law enforcement personnel is usually mandated. ——When the perpetrator is unknown, unrelated, or not considered a caretaker or involved in the child’s care, the abuse may be treated as a purely criminal case. The generally recognized forms of sexual abuse are genital fondling; masturbation; sexualized kissing; digit or object penetration of the vagina or anus; and oral-genital, genital-genital, and anal-genital contact, but the perpetrator does not need to directly contact the child physically for sexual abuse to occur, with exhibitionism; voyeurism; and viewing, producing, or distributing pornography also included in most definitions. The use of computers and the Internet to produce, compile, possesses, or disseminate child pornography as well as to seduce or attract children with the intent of sexual misuse is a recent addition to legislation. In addition, failure to protect a child is an important component of many definitions of child sexual abuse. Incest is a special category in that a different level of psychosocial problems, prognosis, and family dysfunction is involved, but the cases are handled the same with respect to reporting and meeting the legal definition of sexual abuse. Sexual play occurs between young children of similar developmental levels and frequently involves viewing or touching, but it is considered a normal part of childhood development and curiosity. The variety and frequency of sexualized behaviors increase in both male and female children up to 5 years of age and then decreases thereafter. The distinction between sexual play and sexual abuse is generally predicated on the discrepancy in age between the 2 participants, the level of control or authority the older child holds over the younger one, the degree of coercion, and the actual activity involved. Persons who are mandatory reporters, having a responsibility for the welfare of children, should be familiar with their own state statutes.

2 Principles of Sexual Assault at Any Age Chapter 1

Scope ——True magnitude is unknown. ——Rates are generally considered underestimates and are based on substantial underreporting. ——Cases may never be disclosed or may be disclosed by victims but not reported to authorities. ——The Fourth National Incidence Study on Child Abuse and Neglect estimated 135 300 cases of sexual abuse in 2006, a rate of 1.8 cases/1000 children. ——Prevalence studies estimate that 17% of females and 8% of males have experienced childhood sexual abuse. ——One-third of victimized women and 40% of victimized men never disclose. ——Physicians and other mandated reporters often fail to report cases of sexual abuse, with a perceived lack of sufficient evidence, concern for disrupting the patient-physician relationship, fear of harming the family, and distrust of local CPS agencies cited as the most common reasons for not reporting. ——Recall bias may affect the prevalence data reported, with false childhood memories overestimating the true prevalence and denial, repressed memories, and a continuing unwillingness to disclose traumatic events generating an underestimate. Victims ——There is no classic profile of the sexually abused child. ——Female victims account for more than 3 times the number of male victims in reported cases of child sexual abuse. Data also show that girls are 2.5 times more likely to be victims of sexual abuse than boys. ——The risk for sexual abuse is highest during preadolescence with 9 to 11 years being the mean age, with a smaller peak in the early school-age years. ——Sexually abused boys tend to be younger than their female counterparts.

3 Sexual Assault Quick Reference

——Race and ethnicity do not differ from nonabused populations, although there is some evidence that low socioeconomics might increase risk. ——Children with behavioral health problems and physical or mental disabilities are at potentially higher risk for victimization. ——Perpetrators report that they seek children who are available, trusting, lack self-esteem, and have desirable physical attributes. ——Children living without 1 or both of their natural parents are at an increased risk of being abused. Females who live apart from their mothers or are not emotionally close to their mothers are at increased risk of sexual abuse. Abused males are more likely to live with their mothers and have no father figure at home. ——The single most important risk factor for both males and females is the presence of a nonbiologically-related male in the household. ——Other risk factors include having a mother who is ill, disabled, has less than a college education, or is extensively out of the home; substance abuse; parental conflict; violence in the home; having adolescent parents, foster parents, or parents who were sexually abused themselves; and being a sibling of an abused child. Offenders ——There is no classic profile of the abuser. ——Child sexual abusers tend to be older men, but one-quarter to one-third of male perpetrators are adolescents. ——Women are offenders in up to 5% of cases involving female children and 20% of cases involving male children. ——In 75% of cases of child sexual abuse, the perpetrator is known by the child. Stepfathers molest girls more often than boys, while biological fathers molest similar numbers of girls and boys. ——Incest victims are most likely to be female children who are molested by their fathers or stepfathers.

4 2 Chapter

Anogenital Anatomy Eileen M. Allen, MSN, RN, FN-CSA, SANE-A, SANE-P* William J. Reed, MD, FAAP Diana K. Faugno, MSN, RN, CPN, SANE-A, SANE-P, FAAFS, DF-IAFN Patricia M. Speck, DNSc, APN, FNP-BC, DF-IAFN, FAAFS, FAAN

Recognition and understanding of genital and anal anatomy is essential when evaluating patients for sexual assault. The examiner must be familiar with the appearance of normal anatomy in order to recognize injury and/or medical conditions that can influence the physical appearance of the tissue and mimic sexual assault injury. This chapter will identify the genital and anal anatomy of children, adolescents, and adults as well as review the terminology of injury. Medical Embryology of the External Genitalia ——Genetic sex is determined at the time the ovum is fertilized, but during the first 12 weeks of embryonic life, both male and female primordial tracts are present and develop in unison. ——In the female: cortex develops into the ovary at 10 to 11 weeks, with medullary regression. ——In the male: medulla differentiates into the testis, with regression of the cortex. ——Gonadal primordia are influenced by the sex-determining region (SRY) on the Y chromosome. If a functioning testis is present, the phenotype is male, whereas in the absence of the sex-determining region, with or without the presence of an ovary, the phenotype is female.

*Revised Chapter 2 for the second edition.

29 Sexual Assault Quick Reference

Development of External Genitalia in Boys ——External genital development occurs between 10 and 16 weeks of gestation. The genital tubercle grows into a penis and the urogenital folds fuse to enclose the penile urethra. ——At 28 weeks, the inguinal scrotal stage of descent begins, with the testis descending into the scrotal sack between 28 and 32 weeks of gestation. ——Testosterone is responsible for the evolution of the vas deferens, epididymis, ejaculatory ducts, and seminal vesicle. Dihydrotestosterone results in the development of the male external genitalia, including the prostate gland, and the bulbourethral glands, or Cowper’s glands. ——At puberty, testosterone leads to spermatogenesis and the development of the secondary sexual characteristics as well as a five- to seven-fold enlargement of the prostate gland, epididymis, and testes. Anatomic Variations in Boys Many variations of normal and some previously unrecognized problems may be noted in the examination of the male from infancy through puberty stage Tanner G5. The more common variations in genital findings are as follows: ——Leydig cell aplasia or hypoplasia ——Partial androgen insensitivity ——Phimosis ——Paraphimosis ——Hypospadias ——Circumcision adhesions ——Erythema or hyperpigmentation ——Smegma ——Uric acid crystals ——Pink pearly papules of the penis

30 Anogenital Anatomy Chapter 2

——Urethral meatal stenosis ——Epispadias ——Shawl defect ——Micropenis ——Diphallia Development of External Genitalia in Girls ——Female external genitalia develop from the genital groove and urogenital sinus between 6 and 11 to 12 weeks of gestation. ——Among the principal structures are the mons pubis, labia minora and majora, symphysis pubis, clitoral prepuce, vulva, vagina, and hymen. Anatomic Variations in Girls Some congenital abnormalities in females pass undetected in the newborn, becoming clinically apparent only later or remaining partially expressed and found only incidentally during surgery or other procedures. The more prevalent variants are: ——Labial agglutination or fusion ——Premenarchal lichen sclerosis ——Labial hypertrophy ——Midline perineal fusion defect ——Vaginal prolapse ——Vaginal atresia ——Vaginal duplication ——Linea vestibularis ——Skene’s duct cysts ——Prolapse of the urethral meatus ——Paraurethral cysts

31 Sexual Assault Quick Reference

Female external genitalia vary in size, shape, and color. The term “external genitalia” can be confusing to those outside the health care professions and has been used in court to argue that external genitalia are actually outside structures. In reality the introitus contains structures only visible with separation of the labia majora. These anatomical structures are covered with nonkeratinized epithelium making them internal structures. The exposed skin structures, including the mons pubis and the external surfaces of the labia majora, are covered with keratinized cellular structures, hair, and glands. The introitus extends from the mons to the perianal areas and has 3 vulvar openings that are visible. (See Figure 2-1 for a visual reference of female genital anatomy.)

Female Genitalia

Mons pubis

Clitoris

Urethral meatus

Labia majora Labia minora Vaginal introitus

Hymen Fossa navicularis (vestibular fossa) Fourchette Perineum

Anus

Figure 2-1

Figure 2-1. The genital structures of the adult female.

32 4 Chapter

Forensic Evaluation of Children* Diana Faugno, MSN, RN, CPN, SANE-A, SANE-P, FAAFS, DF-IAFN‡ Sarah Anderson, RN, MSN Pamela Ross, MD

The forensic evaluation of a prepubescent child is designed to collect, document, and preserve evidence in a law enforcement investigation of a crime or possible crime. In the event of a crime, the systematic manner of collecting, documenting, and preserving evidence is referred to as process- ing the scene (Figure 4-1).

Figure 4-1

Figure 4-1. Crime scene photograph. Note the yellow place card numbers depicting evidence in the photograph, such as clothing lying on the floor.

*Inherent in the published material is the responsibility of the licensed provider to seek emerging research for evidence-based practice. ‡Revised Chapter 4 for the second edition.

81 Sexual Assault Quick Reference

Principles of Evidence Collection Determination of Team Composition ——Establish a team to provide contamination control; accurately document; prioritize evidence collection; and to collect, preserve, package, transport, and submit evidence by established protocols. ——Team members may be law enforcement, child protective services (CPS), social workers, medical personnel, psychologists, forensic interviewers, and district attorneys. ——All team members need specialized training in pediatric sexual abuse. Contamination Control ——Ensure that the integrity of the evidence is maintained. ——Use nonreusable items to collect specimens and observe universal precautions. Documentation ——Assess what needs to be documented and establish the types of equipment needed, considering photography, video, diagrams, measurements, and notes. 1. Take photographs with and without scale and evidence identifiers. 2. Photograph or videotape to provide a broader perspective and demon- strate correct technique during evidence collection and examination. 3. Document variances with measurements and document location of injuries and evidence collected in relation to the body. 4. Note location of the examination; times of arrival and completion of the examination; general information before evidence collection begins; transient evidence, ie, smells, sights, conditions; and devia- tions from usual standards of practice or care. Prioritization of Evidence Collection ——Prevent loss, destruction, and/or contamination of evidence. 1. Conduct a careful, methodical evaluation, considering all physical evidence possibilities. 2. Focus on easily accessible areas in open view before proceeding to out-of-view locations.

82 Forensic Evaluation of Children Chapter 4

3. Follow a systematic search pattern based on size, type, and location of evidence. 4. Move from least intrusive to most intrusive processing and collection methods. 5. Continually assess environmental factors and other factors that might affect evidence. Collection and Preservation of Evidence ——Maintain evidence security throughout the process. 1. Note location of collected evidence, date and time collected, who collected it, and who had access to it. 2. Establish a chain of custody—document handling and account for all specimens through each step of the evidence processing. Begin with initial collection and follow all the way to the courtroom, thereby ensuring validity and admissibility of forensic evidence in court. 3. Obtain reference samples. Secure any electronically recorded evi- dence immediately. 4. Establish policies and procedures relating to evidence collection and the release of evidence and maintain them, updating periodically. Limitations of the Forensic Evaluation Most nonacute examinations of children who have been sexually abused will show less than 5% visible evidence of findings. There are many reasons for this such as delayed reporting so if there was an injury it has had time to heal. Often the most important evidence will be the child’s history of the event. When to Collect Evidence* Forensic evidence is only collected after initiating law enforcement or CPS investigation. The American Academy of Pediatrics recommends forensic evidence collection when sexual abuse is believed to have occurred within the previous 72 hours or when there is bleeding or acute injury. Many

*The child may have to be taken to the operating room (OR) for this examination, depending on the child’s age.

83 Sexual Assault Quick Reference

programs now recommend 120 hours post assault because DNA analysis technology is more sensitive and continues to change. Process of Collection ——A head-to-toe physical examination, including a detailed genital examination, should be done with the patient in the frog-leg position, either supine or on the caregiver’s lap, and in the prone knee-chest position. Written documentation of evidence, diagrams, and photographs are recommended. ——Physical evidence recovery kits specifically for sexual assaults are usually supplied by law enforcement agencies or can be obtained through a state forensics laboratory (Figure 4-2-a and Figure 4-2-b). Most are designed for adults but are routinely modified for pediatric use. Follow the kit’s instructions on how the evidence should be collected and how to handle used and unused supplies (Table 4-1). ——Collect evidence using normal saline solution, distilled water, or sterile wa- ter, based on the recommendations of the local forensic laboratory. Collect and separately package each piece of clothing worn during and im- mediately after the assault. 1. If the child is still wearing the original clothes, undress the child over a paper sheet placed on a clean hospital bed sheet or another sheet of paper. 2. If the clothing is damp or wet, place examination table paper between the layers and notify the police so the arti- cles of clothing are dried and stored properly. Figure 4-2-a 3. Label each package to identify Figure 4-2-a. Example of an evidence col- the child, date, time, and your lection kit. This kit can be modified by the signature and seal it securely. examiner based on the history of the event.

84 Forensic Evaluation of Children Chapter 4

Figure 4-2-b

Figure 4-2-b. The contents of a physical evidence recovery kit. 4. Initial the seal. 5. Collect linens and bedding, whether they are brought to the emer- gency room or are at the scene, packaging them individually in pa- per bags, sealing them, and turning them over to the police. 6. Instruct the child’s caregivers to minimize bathing, teeth brush- ing, voiding, defecating, vomiting, eating, drinking, and changing clothes after an assault if at all possible. Process of Forensic Evaluations More Than 72-120 Hours After Incident or in Chronic Abuse Based on Your Community Standard ——Do not use a forensic evidence collection kit. ——Perform a head-to-toe physical examination and detailed ano- genital examination, as for acute abuse. ——Document findings and provide diagrams and photographic evidence.

85 Index

A forensic evidence collection, 73, 73t–75t ABO serologic system, 198 laboratory testing after, 181 Abrasions, 180, 424f in males, 123–126, 126t–127t Abusive sexual contact, 393, 394t obtaining history of assault, 171–173, Access dates (computer), 353 187–189, 189t, 219–220 ACOG (American Congress of Obstetricians positions for, 69, 70f–72f and Gynecologists), 233, 250 during pregnancy, 235–236 Acquaintance rape, 241–255 public health implications of, 14 clinician responses to, 244 purposes of, 67 epidemiology of, 241–242 SART model for, 141 preventing, 244–245 scope of, 12–14 risk factors for, 242t sexually transmitted infections and, role of alcohol and other drugs in, 242–243 209–227 victims’ response to, 243 Adult sexual abuse, 12–20 Admissibility of evidence, 382 at-risk populations, 14–15 Adolescent sexual abuse, 12–20 computer-facilitated, 348 at-risk populations, 14–15 defense tactics at trial, 383 defense tactics at trial, 383 delayed effects of, 16–17 delayed effects of, 16–17 disabled, 128–135, 254 documenting and reporting, 167–169 documenting and reporting, 167–169 during pregnancy, 235–236 follow-up care, 183 Internet use and risks of, 433–439, forensic evaluation of, 187–205 436t–439t history of victim, 173 mobility impairment and, 254 laboratory testing after, 181 physical examination, 171–183, 174t, physical examination after, 171–175, 176t, –179t 180–181 common complaints, 60t–61t evidence collection kit, 174t equipment for, 67t–68t obtaining history of victim, 173 follow-up care, 183 public health implications, 14 forensic evaluation and interview, 62, SART model for, 141 63t–66t, 64–65, 187–205 scope of, 12–14

497 Sexual Assault: Quick Reference

sexually transmitted infections and, 209–227 Article 120 of the Uniform Code of Military recommended evaluations for, 221t Justice (UCMJ), 392, 393t–394t See also Elder sexual abuse Assessment questions and tools Advocates, 146, 148 for Internet users, 437-439, 437t-439t African American females, 35, 39 for strangulation victims, 428, 429t–431t Aggravated sexual contact, 393, 394t for victims of trafficking, 402, 402t-403t Agoraphobia, 405 Autonomic nervous system, 284–285 Alcohol, 242–243, 413t ALS (Alternate light source), 89, 190 B American Academy of Pediatrics, 83–84 Bacterial vaginosis, 112t, 114t, 116t, American Board of Forensic Odontology, 121–122, 212t 347, 429f Bail, 364–365 American Congress of Obstetricians and Behaviorally impaired victims, 130–131 Gynecologists (ACOG), 233, 250 Behaviors American Nurses’ Association, 324 physically abusive, 246, 246t Amnesia, 288 self-exploitation and sexting, 434 Amsel’s criteria, 122 stages of behavior change, 304–305, Anogenital anatomy 305t–306t anal anatomy, male and female, 50–52 of strangulation victims, 422t anal warts, 102, 103f Behçet’s syndrome, 105 anus, 50, 50f, 96 Big Blue Swab, 90, 90f–91f anus orifice, 50 Biological evidence in sexual assaults, 201t, pectinate, 51 202–203 perianal skin folds, 50 Bite marks, 92, 204, 347 perineum and anorectum, normal, 51–52 Blood sample collection, 195t perineum and anorectum, variations, 52 Boy Code, 123 rectum, 51, 51f Bruising, 180, 424f–425f female, 175f, 176t–178t Burnout, 313–314 development of external genitalia, 31–32 puberty, 47–48 C variations of normal genitalia, 95, 96f CAPTA (Child Abuse Prevention and Treatment Act of 1974), 1 healing after anogenital injury, 52–54, 53f Caregivers male, 176f, 179t avoiding and treating vicarious development of external genitalia, 30–31 traumatization, 313–322, 320t–322t puberty and variations in, 49 caregiver burden, 313 variations of, 30–31 EMS personnel, 328–331 medical embryology of external genitalia, 29 obtaining child’s history from, 59–60, 62 sexual maturity rating, 48, 48t–49t as perpetrators of elder sexual abuse, 268 Antibiotics to treat STIs, 75, 210t–212t, 213, sexual assault nurse examiners (SANEs), 214t–215t 323–326

498 Index

Sexual Assault Response Coordinators, equipment for, 67t–68t 394–395, 395t–396t findings of concern in, 73 sexual assault response team (SART), follow-up care, 75–76, 76t 326–328 forensic evaluation and interview, 62, for victims of human trafficking, 418 63t–66t, 64–65, 73, 73t–75t, 81–93 Case management, 354–355 obtaining history of, 59–66 Case studies positions for, 69, 70f–72f diaper dermatitis and constipation, 106, 106f procedure, 67t–68t, 68–69 straddle injury, 98, 98f purposes of, 67 Cavernous hemangiomas, 101, 101f scope of, 3 Centers for Disease Control and Prevention sexually transmitted infections, 111–112, (CDC), 75–76, 210t–212t 112t–116t. See also specific infections Cervical os, 44 support systems, 8 Cervix, 43, 43f victim profiles, 3–4 Chain of evidence, 169, 192, 193f, Chlamydia trachomatis, 112t, 115t, 116–117, 193t–195t, 330 209–210, 211t, 215 Chancroid, 212 treatment of, during pregnancy, 236 Circumcision, 46 Child abuse, nonsexual, 231, 234–235 Clitoral hood, 33 Child Abuse Prevention and Treatment Act of 1974 (CAPTA), 1 Clitoris, 33 Clothing, collection of, 84, 193t, 339 Child Advocacy Centers, 8 CODIS (Combined DNA Index System), Child Protective Services (CPS), 157 196, 200–201 investigation, 83 Cognitively impaired victims, 130–131 as part of multidisciplinary team, 141, Colposcopy, 89, 166 144, 145f, 146, 147t, 148 Combination trader-travelers (online Child sexual abuse predators), 435 coping mechanisms, 10–11 Combined DNA Index System (CODIS), defense tactics at trial, 383 196, 200–201 disabled, and sexual violence, 128–135 Community-based programs, 302–303, 325 documenting and reporting sexual abuse, Community standards 157–167 and CDC guidelines for follow-up care, 76 forms of, 2 for crimes of sexual assault, 361 indicators of, 6–8 for evidence collection, 85, 203–205 Internet and, 433–439, 436t–439t Compassion fatigue, 313 interventions for, 11–12 Complaints of sexually abused children, 60t–61t legal definitions, 1–2 Computers outcomes, 9–10 forensic evaluation of, 350–351 perpetrators of, 4–6 sexual exploitation of adult victims, 348–351 physical examination of, 59–76 See also Internet common complaints of, 60t–61t Condoms, 204

499 Sexual Assault: Quick Reference

Conflict resolution, 142–143, 143t Defense attorneys, 360 Constipation, 105, 106f appointment of, 365 Contamination control, 82 DNA evidence and, 379 Contraception, 226–227, 226t–227t, 236, 244 expert witnesses and, 378 Convicted offender databases, 200 role of, 381 “Cookies” (file on computer), 351 trial and, 381, 383 Coping mechanisms, 10–11 Department of Defense Directive (DODD), Corona of the glans, 46 395, 395t-396t Correctional settings Depression, 16, 229 consequences of sexual abuse in, 277 Dermatologic disorders, 100–102, 100f–101f factors contributing to sexual abuse in, DESNOS (Disorders of extreme stress not 274–276 otherwise specified), 405, infections diseases in, 278, 278t 406t–407t, 407 risk factors for inmates, 277 Diaper role of medical professionals, 277–278, 278t bloody, in straddle injury, 98, 98f staff, 279 dermatitis, 104, 106, 106f statistics, 276 Differential diagnosis, 95–106 Corroboration, 346, 366–367 dermatologic disorders, 100–102, 100f–101f Cough, 105 infectious disorders, 102–104, 103f–104f, 278, 278t Counsel. See Defense attorneys inflammatory disorders, 104–105 Countertransference, 314 miscellaneous disorders, 105, 106f Court and judicial proceedings, 148–151 nonabusive trauma, 96–98, 97f–98f Courts-martial, 391–392 variations of normal anatomy Cowper’s glands, 47 anus, 96 CPS (Child Protective Services), 83, 141, genitalia, 95, 96f 144, 145f, 146, 147t, 148, 157 Digital cameras, 89 Created dates (computer), 353 Direct examination, 367t–376t Crime scene preservation Disability and sexual violence legal issues, 329–331 adolescents with mobility impairment, 254 photograph of, 81f, 338–342 adults, 128–135, 254 role of EMS in, 338–342 children, 128–135 Criminal courts, 150–151 DNA testing, 133 Criminal justice process, 363–364 evaluation of victims, 129–131 Crohn’s disease, 104–105 homicide, 133 Cultural competency, 417 interview techniques, 131–132 Cyberstalking, 348 multidisciplinary considerations, 133–135 in nursing and group homes, 129 D physical examinations, 132–133 Date rape. See Acquaintance rape; Intimate reasons for occurrence, 128–129 partner rape women victims, 254

500 Index

Disorders physically abusive behaviors, 246, 246t dermatologic, 100–102, 100f–101f during pregnancy, 229–237 infectious, 102–104, 103f-104f, 278, 278t programs for survivors of, 298 inflammatory, 104–105 psychologic effects of, 249 miscellaneous, 105 risk factors for, 246 Disorders of extreme stress not otherwise role of coercion in, 247–248 specified (DESNOS), 405, role of pediatricians in preventing, 234–235 406t–407t, 407 screening for, 249–251, 250t “Disorganization phase” of rape trauma, 16 sexual abuse and, 247, 298 Dissociation, 289 special populations, 254–255 DNA Don’t ask - don’t tell, 303–305 databases, 196, 381 Double swab technique, 89 evidence in court proceedings, 379–381 Draping for surgical repair, 99f forensic testing, 133, 197–200 Drugs, 242–243, 413t importance of evidence collection, 196–197 DNA Identification Act of 1994, 200 E Documentation Ecchymosis, 180, 220 abuse against adolescents and adults, Edema, 180–181 167–169 Elder sexual abuse child sex abuse, 82, 157–167 defining, 263–264 the electronic record, 166–167 the forensic interview, 158 examination of victims, 272–274 formulating a diagnosis, 163 exposure to, 264 the medical record, 159–163 framework for working with victims of, 269–270 networks to medical providers, 163–164 immediate and long-term responses to, domestic violence, 251-252 268–269 evidence collection, 92 interviews with victims, 271–272 forensic evidence, 82, 331 in noninstitutional settings, 268 DODD (Department of Defense Directive), 395, 395t–396t in nursing homes, 264–267 Domestic violence police and, 356 clinician’s response to, 230–231, 233–234 provision of care and resources in, 274 documenting, 251–252 reporting and investigating suspected, 267 hotline, 252 reporting requirements, 274 intersection with HIV, 249 screening for, 270–271 intervention for, 252–253 signs of, 265–266 link with child abuse, 231 Electronic record, 166–167 marital rape as, 253 E-mail headers, 351, 352t overview of, 245–246, 246t Embryology of external genitalia, 29 physical injuries and symptoms of, Emergency contraception, 226–227, 248–249, 248t 226t–227t, 236, 244

501 Sexual Assault: Quick Reference

Emergency rooms FBI (Federal Bureau of Investigation), 200 personnel, 18 FE (Forensic examiner), 324 treatment for strangulation victims, 429, Fellatio syndrome, 190f 430t–431t Females Emotions and trauma, 289 anal anatomy, 50–52, 50f–51f EMS hospital care providers, 338 genitalia, 33–35 forensic evidence and, 329–331 development of external, 31–32 police and, 358 hymen, 35–42, 38f–39f, 41f–42f psychology of victims and, 328–329 medical embryology of, 29 transporting victims to hospitals, 331 puberty, 47–48 Encryption, 349 reproductive parts, 42–44, 43f Endorphins, 289–290 Tanner stages of maturity, 48, 48t–49t Enterobius vermicularis (Pinworms), 104 PTSD in, 291 Envelope, evidence, 193f. See also Evidence recommended evaluation for STIs, 221t collection kits as victims of trafficking, 412t–417t Epstein-Barr infection, 103 Fingernails, 194t Equipment for sexual assault examination, Fingerprints, 340 67t–68t First responders, 356–361 Estrogen effect, 36t-37t Flashbacks, 288 Eversion, 44 Flight-or-fight response, 286 Evidence collection kits, 73, 84f–85f, 133, Foley catheter, 90 174t, 193f, 325, 343. See also Follow-up care, 183, 221, 300 Forensic evidence Forensic dentists, 347 Examinations. See Laboratory testing; Forensic evidence Physical examinations admissibility of, 382 Expert witnesses adolescents and adults, 73, 73t-75t for DNA evidence, 380 acute care of, 189–192, 190f factors for successful, 377–379 chain of evidence, 192, 193f, 193t–195t qualifications of, 376–377 DNA testing, 198–205, 201t response suggestions, 367t–376t medical history, 187–189 Extropion, 44 children, 73, 73t–75t, 81–93, 193t–195t, 196 collection and preservation of, 83, F 86t–87t contamination control, 82 Fact witness, 376 documenting, 82 Fallopian tubes, 44 EMS hospital care providers and, 329–331 Family members prioritization of, 82–83 interviewing, 345 process of, 84–85, 84f–85f, 86t–87t as perpetrators of abuse, 268 special techniques, 88–90, 90f–91f, of sexually abused boys, 126t–127t 92–93 as support system, 301 team members for, 82 See also Caregivers when to collect evidence, 83–84

502 Index

community standards, 203-205 H of computers, 350–351, 352f, 353 Haemophilus ducreya, 212 corroborating, 346 Hair, 194t, 203–204 evidence collection kits, 73, 84f-85f, 133, HBV (Hepatitis B), 218, 278 174t, 193f, 325, 343 Healing after anogenital injuries, 52–54, 53f interviews, 158 Health care providers legal issues, 338–342 in correctional institutions, 277–278, 278t limitations of, 83 photographs, 81f, 88–89, 92, 166-167, and elder sexual abuse, 270–271 340–341, 347, 350, 428, 424f-427f Internet safety and, 437–439, 436t–437t time frame, 83–84 limitations of, 303–305, 305t–306t See also Physical examinations; Sexually networks of, 163-164 transmitted infections prehospital personnel, 17 Forensic examiner (FE), 324 response to abuse during pregnancy, 233–234 Forensic index, 201 response to abuse from acquaintance rape, Foreskin, 46 244 Forty-eight to 72 hours after attack, role of, in obtaining history of assault, instructions for strangulation 171–173 victims, 429, 430t–431t screening, documentation, and Fossa navicularis, 34 intervention for domestic violence, Fourth National Incidence Study on Child 249–253, 250t Abuse and Neglect, 3 for trafficked persons, 401–403, 402t–403t, 411, 417–418 G victims of sexual assault and, 298–300 Gardnerella vaginalis, 121 See also Caregivers Gastrointestinal system, 161 Hearing-impaired victims, 130 Gender differences and trauma reaction, 408 Hemangiomas, 101, 101f Genitalia Hematoma, 426f female, 175f, 176t–178t Hepatitis A, 218, 278 male, 44, 45f, 46–47, 176f, 179t Hepatitis B (HBV), 218, 278 physical examination and evidence Hepatitis C, 218, 278 collection, 195t Hepatitis D, 278 variations of normal, 95, 96f Heredity, 284–285 Genitourinary system, 160–161 Herpes simplex viruses (HSVs), 103, 112t, Gerontology, 269 114t, 116t, 119–120, 211t, 236 Glans penis, 44 HERS (Hymen Estrogen Response Scale), Glasgow Coma Scale, 428 39, 40t Gonorrhea, treatment options, 210t History directory (of web sites), 351 for children, 115t HIV. See Human immunodeficiency virus in pregnancy, 236 Homicide, 133, 246 Group home residents, 129 Hospital-based programs, 324–325

503 Sexual Assault: Quick Reference

Hotlines Immigrants, 254 for domestic violence, 252 Infectious diseases and disorders, 102–104, for human trafficking, 403 103f-104f, 278, 278t for missing and exploited children, 439 Inflammatory disorders, 104–105 for prosecution of child abuse, 353 Information technology terms, 440a–442a HPA Axis, 292, 316 Injuries HPV (human papillomavirus), 102, 103f, to anogenital area, 52–54, 53f 112t, 113t, 115t, 120-121, 236 domestic violence, 248, 248t HSVs (Herpes simplex viruses), 103, 112t, interpreting, 182, 182t–183t 114t, 116t, 119–120, 211t, 236 sustained by trafficked persons, 408–410, Human immunodeficiency virus (HIV), 409f 112t, 116t, 118 TEARS (acronym for types of), 180–181, among trafficked persons, 410–411 220 domestic violence and, 249 Instant messaging, 353 postexposure prophylaxis, 223t, 224–225 International Association of Forensic Nurses in prison population, 278t (IAFN), 326 treatment of, during pregnancy, 237 Internet Human papillomavirus (HPV), 102, 103f, and adult sexual abuse, 348 112t, 113t, 115t, 120–121, 236 global nature of, 433 Human trafficking, 399–418 glossary of new media and information identifying victims, 401–403, 402t–403t technology terms, 440a–442a mental health impacts of, 404–405, 404f, Internet access devices (IADs), 433 405t–407t, 407–408, 413t risks of, 433–435 physical health impacts of, 408–411, 409f, 412t role of health care providers and, 437–439, statistics, 399 436t-437t trafficker-victim dynamics, 400–401 safety guidelines and supervision, 19, 435–437, 436t-439t trauma-informed practice and, 411, 417–418 Hymen, 35–42 Interventions inspection of, 40, 41f–42f, 42 for child victims, 11 irrigation of tissue, 90 for domestic violence, 252–253 tissue response to estrogen, 36t–37t Interviews and interviewing types of, 37, 38f–39f of adolescents and children, 62, 63t–66t, Hymen Estrogen Response Scale (HERS), 64–65 39, 40t of caregivers, 59–60 Hypothalamic-pituitary-adrenal axis, 292, 316 in computer-facilitated sexual assault cases, 348–350 I of disabled children and adults, 131–132 IADs (Internet access devices), 433 documenting and reporting, 158 IAFN (International Association of Forensic of elderly sexual assault victims, 271–272 Nurses), 326 vs. interrogations, 343

504 Index

legal issues, 342–345 computer-facilitated sexual exploitation of and police, 359 adults, 347–351, 352t, 353 protocol, 63t–64t the interview process, 342–345 of suspects, 344 police as first responders, 356–361 of victims, 344–345 processing the scene and collecting Intimate partner rape, 241–255 evidence, 338–342 effective clinician responses to, 244 corroborating evidence, 346, 366-367 epidemiology of, 241–242 from prosecutor’s perspective, 361–367, preventing, 244–245 367t–376t, 376–382 risk factors for, 242t role of investigator, 337 role of alcohol and other drugs in, 242–243 search warrants, 345–346 victims’ response to, 243 Learned helplessness, 286–287 Intrauterine device (IUD), 226, 226t Legal issues investigation and prosecution, 337–355 J of trafficked women, 416t Jeffreys, Alec, 198 United States military and, 390–392 Joint Commission on the Accreditation of Lenehan, Gail, 323 Healthcare Organizations Lesbian, gay, bisexual, transgender, and queer (JCAHO), 323 (LGBTQ) relationships, 255, 356 Judicial proceedings, 148–151 Lichen sclerosus et atrophicus, 100, 100f Juries, 381–382, 384 Ligature marks, 422, 422f Juvenile courts, 149–150 Locard’s exchange principle, 330 K M Kawasaki syndrome, 105 Macrophotography, 166 Males L anal anatomy, 50–52, 50f–51f Labial agglutination, 105, 106f genitalia Labia majora, 33 external, 29-31, 176f, 179t Labia minora, 33–34, 105, 106f puberty and variations in development, 49 Laboratory testing reproductive parts, 46–47 after sexual assault, 181 Tanner stages of maturity, 48, 48t–49t for sexually transmitted infections (STIs), visible, 44, 45f, 46 113t–116t recommended evaluation for STIs, 221t Lacerations, 180 relationship with police, 356 Lactobacillus, 121 sexual abuse of boys and adolescents, Law enforcement issues 123–126, 126t–127t agencies, 145t, 146 Malware, 435 bite marks, 347 Mandated reporters, 2, 325, 436, 436t case management, 347–351, 352t, 353 Marital rape, 253

505 Sexual Assault: Quick Reference

Medical examination reporting sexual assault and abuse, of adolescents and adults, 168–169 143–144, 145f nonforensic aspects of, 169 in sexual assault of disabled, 133–134 police transport of victims for, 359 shared responsibility and, 142 purpose of, for child sex abuse, 158 See also Health care providers Medical history Multi-locus probe, 198 of adolescents and adults, 168, 171–173 Mycoplasma hominis, 121 documenting, 159–160 provided by child, 59–66, 159–162 N Medical records NAATs (Nucleic Acid Amplification Tests), of adolescents and adults, 168 113t, 117, 118, 120 of children, 158–163 National Center for Missing and Exploited components of, 160–161 Children (NCMEC), 436t, 439 electronic, 167 National Crime Victimization Survey, 12 Memorandum of understanding (MOU), 395 National District Attorneys Association. Mental health National Center for Prosecution of Child effects of sexual assault, 151–152 Abuse, 353 impacts of trafficking, 404–405, 404f, National domestic violence hotline, 252 405t–407t, 407–408 National Prison Rape Elimination professionals, 148 Commission, 276 ramifications of prison abuse, 277 Neisseria gonorrhea, 102, 117–118, 215 Military. See United States military Networks of health care providers, 163–164 Miranda warnings, 363 Neurobiology, 291 Modified dates (computer), 353 New media Molluscum contagiosum, 103, 104f glossary of terms, 440a–442a MOU (Memorandum of understanding), 395 health care providers and, 437–439, 437t Mucopurulent cervicitis, 213 risks of, 433–435 Multidisciplinary teamwork, 141–152 safety guidelines and supervision, benefits of, 142 435–436, 436t collaborative investigation and intervention understanding, 433 with CPS, 144, 145f, 146, 147t 911 calls, 338, 363 with law enforcement agencies, 146 Nonforensic examination aspects, 169 mental health professionals, 148 Nucleic Acid Amplification Tests (NAATs), sexual violence advocates, 146, 148 113t, 117, 118, 120 court and judicial proceedings, 148–151 Nursing homes criminal courts, 150–151 perpetrators in, 266–267 juvenile courts, 149–150 reporting and investigating abuse in, handling conflicts, 142–143, 143t 267, 274 impact on victim, 151–152 sexual abuse in, 129, 264–267

506 Index

O in nursing homes, 266–267 relationships with victims, 13–14 Offender index, 201 of sexual violence against disabled, 128 Offenders. See Perpetrators Petechiae, 426f Ondontologists, 347 Pharmacologic needs in forensic 120 hour window for collection of forensic examination, 196 evidence, 83–84, 85, 88 Photographs Online predators, 434–435 of bite marks, 347 Oropharynx, 194t in child sexual abuse, 88-89 Ovaries, 44 of computers, 350 P of crime scene, 81f, 340–341 digital, 92, 166–167 P2P (peer-to-peer) networks, 433 pornographic, 435 Paper hardcopy, 167 of strangulation victims, 422f, 424f-427f, Parents and parenting 428 and Internet safety, 19, 436t–439t Phthirus pubis, 216 recommendations for parents of sexually- Physical examinations abused boys, 126t–127t adults, 173–175 and sexual assault , 294 disabled, 132–133 See also Caregivers follow-up care, 183 Passwords, 349 interpreting injuries, 182, 182t–183t PCR (Polymerase chain reaction) analysis, 199–200 laboratory tests, 181 Pectinate, 51 obtaining history of assault, 171–173 Pediatricians, 234–235 of children and adolescents, 59–76, 173–175 Pediculus pubis (pubic lice), 216–217 common complaints of, 60t–61t Peer review of cases, 93 disabled, 132–133 Peer-to-peer (P2P) networks, 433 equipment for, 67t–68t Pelvic inflammatory disease (PID), 213, 214t–215t examination checklist, 76t Penicillin, 237 findings of concern in, 73 Penis, 44, 45f follow-up care, 75–76, 76t, 183 PEP (Postexposure prophylaxis), 224 forensic evidence collection, 73, 73t–75t Perianal skin folds, 50 interpreting injuries, 182, 182t–183t Perineum, 44, 51–52 interviews, 63t–66t Perpetrators laboratory tests, 181 of child sexual abuse, 4–6 obtaining history of assault, 59–66, 171–173 databases for convicted, 200 positioning for, 69, 70f–72f move from victim to predator, 279 purposes of, 67 in noninstitutional settings, 268 recording findings of, 162–163

507 Sexual Assault: Quick Reference

Physical health effects of sexual assault Pregnancy and sexual assault, 229–237 in adults, 151–152 of adolescents, 235–236 in trafficked victims, 408-410 clinician response to, 230–231, 233–235 Physician-patient relationship, 158–159 domestic violence during, 229–236 PID (Pelvic inflammatory disease), 213, emergency contraception, 226-227, 214t–215t 226t-227t, 236, 244 Pinworms (Enterobius vermicularis), 104 link with child abuse, 231, 234–235 Police prophylaxis and treatment of STIs in, as first responders, 356–361 236–237 as part of multidisciplinary team, 145f, 146 and SANE nurses, 324 investigative interviews, 359 Prehospital personnel, 17 ongoing contact and support with victims, Preliminary arraignment, 364–365 361 Preliminary hearing, 365–366 transport of victims for medical Prevention programs, 19–20 examinations, 359 Prison Rape Elimination Act (PREA), 276 victim reactions and, 360–361 Prisons. See Correctional settings Polymerase chain reaction (PCR) analysis, Probable cause, 364 199–200 Processing the scene, 81f Posterior fornix, 42 Procititis, 215, 216t Posterior fourchette, 34, 35f, 98f-99f Proctocolitis, 215, 216t Postexposure prophylaxis (PEP), 224 Prophylactic treatment following sexual abuse Posttraumatic stress disorder (PTSD) for adults, 222, 223t, 224–225 children with mothers diagnosed with, 294 pregnancy prevention, 226–227, 226t–227t as consequence of trauma, 290, 291 Prosecutor and prosecution as delayed effect, 16 and community values, 361 differences between men and women, 408 corroborating evidence, 366–367 formal diagnosis of, 284 criminal justice process, 363–364 health consequences of, 292 direct examination, 367t–376t human trafficking and, 405, 417 DNA evidence, 379–381 as result of dating and acquaintance rape, and first responders, 360 243 legal issues, 361–384 as result of domestic violence during preliminary arraignment, 364–365 pregnancy, 229 as result of prison attacks, 277 preliminary hearing, 365–366 in sexual abuse survivors, 279 questions at trial, 367t–376t similarity to rape trauma syndrome, 269 reasons for prosecution, 151 similarity to vicarious traumatization, 313 statute of limitations, 362 in women, 291 trial, 381–384 Prader, Andrea, 49t witnesses, 367, 376–379 PREA (Prison Rape Elimination Act), 276 Prostate gland, 47

508 Index

Psychologic effects Reproductive parts of acquaintance rape, 243 female, 42–44, 43f of domestic violence, 249 male, 46–47 of vicarious traumatization, 317 Restriction fragment length polymorphism PTSD. See Posttraumatic stress disorder (RFLP), 198–199 Puberty Revictimization, 293 female, 47–48 Risk factors males, 49 for acquaintance rape, 242t Pubic lice (Pediculus pubis), 216–217 for children and adolescents on the Public health implications of sexual abuse, 14 Internet, 433-442 Punishments, military, 391–392, 393t-394t for domestic violence, 246 for prisoners, 277 R for sexual assault, 14–16, 242t RADAR model, 252 for trafficked persons, 399–400 Rape for vicarious traumatization, 315 acquaintance and intimate partner, 241–255 Rugae, 50 defined, 12, 263–264, 393–394 marital, 253 S in military, 392–394 SAFE (Sexual assault forensic examiner), in older adults, 263–279 142, 324 exposure to, 264 Safety assessment, 253, 304 residents of nursing homes, 264–267 Saline float/irrigation of hymenal tissue, 90 signs of, 265–266 Saliva, 197 Rape crisis centers, 17, 297, 301 Sanctuary, 295 Rape kits. See Evidence collection kits SANE. See Sexual assault nurse examiners Rape trauma syndrome, 268–269, 297, SAPR (Sexual Assault Prevention and 360–361 Response program), 394–395, Recantation of sexual abuse, 8 395t–396t Rectum, 51, 51f SARC (Sexual Assault Response Coordinator), Redness, 180, 220 394–395, 395t-396t Religious groups, 300–301 Sarcoptes scabiei, 217 “Reorganization phase” of rape trauma, 16 SART (Sexual assault response team), 134, Reporting requirements 141, 299-300, 326-328 child sexual abuse, 143–144, 146–147, Scabies, 104, 217 157–167 Scrotum, 46 to CPS, 144, 145f, 146, 147t Search warrants, 345–346 elder abuse, 267, 274 Self-harm, 407, 408f in military, 395, 395t–396t Semen, 197 sexual abuse of adolescents and adults, Seminal vesicles, 47 167–169 Serologic tests, 197–198

509 Sexual Assault: Quick Reference

Seventy-two–hour time frame evidence collection kit, 73, 84f–85f, 133, for emergency contraception, 236 174t, 193f, 325, 343 for evidentiary examination, 325 examination checklist, 76t for HIV postexposure prophylaxis, 223t, 224 formulating diagnosis of, 163–164 to 120 hours for evidence collection in and homicide, 133, 246 child sexual abuse, 65, 83-85 immediate reactions to, 15–16 Sexting, 434 mental health effects of, 151-152 Sexual abuse and assault in military, 389–396 acute care of victim, 189–192 and neurobiologic changes, 291 biological evidence in, 201t, 202–203 nonreporting of, 13 in boys and male adolescents, 123–126, and parenting, 294 126t–127t physical health effects of, 152 coordination of services, 302–303 pregnancy in correctional settings, 274–279 during, 229–237 consequences of attacks, 277 resulting in, 236 overview of, 274–276 prevention programs, 19–20 role of medical professionals in, reporting, 143–144, 146, 148 277–278, 278t in military, 395, 395t–396t scope of problem, 276 and revictimization , 293 creating sanctuary for survivors, 295–296 risk factors for, 242t as crime, 361–362 social supports for victims of, 297–303 definitions of sexual conduct, 189t transporting victims to hospitals, 331 of disabled children and adults, 128–135 traumatic nature of, 283–296 and domestic violence, 247 Sexual assault forensic examiner (SAFE), effective response to, 17–18 142, 324 of elderly Sexual assault nurse examiners (SANEs), 18 definition of, 263–264 and abuse during pregnancy and, 233 examination of, 272–274 advantages of, 328 exposure to, 264 in assault of disabled, 134 framework for working with, 269–270 definitions, 324 immediate and long-term responses to, history of program development, 323–324 268–269 as mandated reporters, 325 interviewing, 271–272 need for, 323 in noninstitutional settings, 268 operation of program, 324–325 provision of care and resources, 274 roles and responsibilities, 18, 299–300, reporting requirements, 274 325–326 residents of nursing homes, 129, scope of practice, 324 264–267 training, 326 screening for, 270–271 as witnesses, 367, 367t–376t signs of, 265–266

510 Index

Sexual Assault Prevention and Response Soul murder, 296 program (SAPR), 394–395, Stages of Behavioral Change Model, 395t–396t 304–305, 305t–306t Sexual Assault Response Coordinators Staphylococcus aureus, 102 (SARC), 394–395, 395t-396t State forensics laboratory, 84–85 Sexual Assault Response Team (SART) Statute of limitations, 362 for adolescents and adults, 141 STIs. See Sexually transmitted infections composition of, 134, 299–300, 326–328 Straddle injuries, 96, 97f–99f, 98 types of, 327 Strangulation Sexually transmitted infections (STIs) assessment tools for, 428, 429t–430t among trafficked persons, 410–411 categories of, 421 assessment of risk, 112–113, 209–210, emergency room treatment, 429, 430t–431t 219t–220t photographs of injuries, 422f, 424f–427f, in children 428 laboratory tests, 113t-114t signs and symptoms of, 421–423, 422t–423t treatment options, 115t-116t Strawberry hemangiomas, 101, 101f diagnostic evaluation for, 221t, 222 Stress as indication of child sexual abuse, 7 and endorphins, 289–290 modes of transmission, 112t and impairment of clear thinking, 287 patient history and physical examination, and memory, 287–289 219–220 moods and immunity, 292 postexposure prophylaxis, 76, 223t, 224–225 Subconjunctival hemorrhage, 427f in prison population, 278 Substance abuse, 16–17 recognition and treatment of, 210, Surveys, 12 210t–212t, 212–213, 214t–216t, Suspect Evidence Collection Kit and 215–218, 222, 223t Protocol, 343 during pregnancy, 236–237 Suspects and SANE nurses, 324 assessing knowledge of computers, 348–350 types of, 116–123 interviewing, 342–344 See also specific infections in computer-facilitated sexual assault Sexual play, 2 cases, 348–350 Sexual violence advocates, 146, 148 and search warrants, 342–346 Shoes, 204 Swabs, 190, 193t, 202–203 “Silent” victims, 13 Swelling, 180–181, 220 Skin, 194t Syphilis, 112t, 113t, 115t, 118–119, 237 Slides, 167 Social media, 433–435 T Social service professionals, 279 Tanner stages of maturity, 48, 48t–49t Social supports, 297–303 TB (Tuberculosis), 278t Sodomy, 394 Tears, 180 “Some Other Dude Did It” defense, 349 TEARS (acronym for types of injuries), 180–181, 220

511 Sexual Assault: Quick Reference

Technologies, 165–166 Trauma bonding, 290 Telemedicine, 164–165 Trauma reaction spectrum, 404f Temporary Internet files file, 351 Trauma reenactment, 290 Testes, 46 Trauma theory, 283–291 Toll-free complaint line for human Traumatic reaction factors, 405t trafficking, 403 Travelers (online predators), 435 Toluidine blue dye, 92, 106f, 163, Treponema pallidum, 113t, 118–119, 215 168–169,192, 331 Trial, 381-384 Traders (online predators), 435 Trafficked persons Trichomonas infections, 113t, 115t, 120, 236 health consequences for, 411, 412t–417t Trichomonas vaginalis, 112t, 120 mental health impacts of, 404–405, 404f, TTM (Transtheoretical Model of Change), 405t–407t, 407–408 304–305, 305t–306t methods of control of, 400–401 Tuberculosis (TB), 278t non-Western health practices for, 417 obstacles to identifying, 401–403, 402t–403t U physical injuries sustained by, 408–411, 409f Uniform Code of Military Justice (UCMJ), risk and abuse encountered by, 412t–417t 390–392, 393t-394t risk factors for, 399–400 United Nations, 410 self-harm inflicted by, 407, 408f United States Air Force, 390 sexual health of, 410–411 United States Air National Guard, 390 Traffickers United States Army, 389–390 characteristics of, 399–400 United States Department of Defense, methods of control, 400–401 389–390, 394–395 Transportation United States Department of Justice, 276, 403 of computers, 351 United States Department of Justice Office of of seized items, 351 Violence Against Women, 219 of victims to hospitals, 331, 359 United States Department of Labor Transtheoretical Model (TTM) of Change, 304–305, 305t–306t Trafficking in Persons and Worker Trauma Exploitation Task Force, 403 addiction to, 289–290 United States Federal Bureau of Investigation anogenital, 52–54, 53f (FBI), 200 consequences of, 290–291 United States Marine Corp, 390 and emotions, 289 United States military health consequences of, 292–296 branches of, 389–390 -informed model of care, 411, 412t–417t definitions of rape and sexual assault in, nonabusive, 96–97, 97f–99f 392–394 reaction to legal system, 390–392 and gender differences an, 408 Article 120 Uniform Code of Military immediate, 15–16 Justice, 392, 393t–394t See also Posttraumatic stress disorder; sexual assault prevention and response, Vicarious traumatization 394–395

512 Index

restricted reporting, 395, 396t assessment of STI risk for, 219t–220t sexual assault response coordinator at-risk populations, 14–16 (SARC), 394–395 barriers to nonreporting, 13, 303–304 unrestricted reporting, 395, 395t contact with first responders, 357 United States Navy, 390 in correctional facilities, 277 United States Secretary of Defense, 389 evaluation and treatment for STIs, Urethral meatus, 34–35, 46 219t–220t, 222, 223t, 224–227, Uterus, 42–43 226t–227t health effects, 292 V impact of assault on, 151–152 VA (victim advocate), 395 and Internet, 439 Vagina, 42 legal aspects of interviewing, 342–345 in military, 389–395, 393t–396t Vaginal introitus, 42 move to predators, 279 Vaginal rugae, 42 ongoing contact and support with Varicella, 278 police, 357–358, 360–361 Vasa deferentia, 46 relationship with assailant, 13–14 VAWA (Violence Against Women Act), response to dating violence and 144, 323 acquaintance rape, 243 Vehicle identification number (VIN), 341 role of EMS for, 328–331 Venous congestion, 426f silent, 13 Vestibular bands, 34, 95, 96f social supports of, 297–303 Vestibule, 34 as survivors, 295, 328 Vicarious traumatization, 418 transporting to hospitals, 331, 359 causes of, 316–320 of strangulation, 421–431 biologic, 316–317 assessment of, 421–423, 422f, 424f–427f, organizational settings, 318 428–429, 429t–431t, 429f psychologic, 317 emergency room treatment, 429, social, 317–318 430t–431t theoretical conflicts, 319–320 thought processes of, 423t definitions, 313–314 See also specific categories of victims protective factors, 316 Victim-to-victimizer behavior, 293 risk factors for, 315 Video clips, 167 Videotapes, 167 solutions for, 320, 320t–322t VIN (Vehicle identification number), 341 symptoms of, 314–315 Violence Against Women Act (VAWA), 144, Victim advocate (VA) program, 395 323 Victimology, 269 Viral hepatitis, 217–218 Victims Visually impaired victims, 130 of sexual assault Vulva, 33, 102 acute care of, 189–192 Vulvovaginitis, 102

513 Sexual Assault: Quick Reference

W Warts, 102 Weather, 339 Web sites, 351, 439 Witnesses, 367, 376–379, 381 Wood’s lamp, 89, 169, 190 World Health Organization, 249, 410 Wrongful sexual contact, 394, 394t

514