A National Protocol for Sexual Assault Medical Forensic Examinations Adults/Adolescents Second Edition U.S. Department of Justice Office on Violence Against Women April 2013 NCJ 228119 Acknowledgments Many individuals contributed their skills and expertise to the development of this protocol. Special appreciation goes to Kristin Littel, who served as the primary writer and researcher for the protocol. We would also like to thank the Office for Victims of Crime for initiating this project and for providing feedback and guidance throughout the drafting process. We are grateful to all of the women and men who gave their time and energy to attend the focus groups, participate in the conference calls, and review numerous drafts of the protocol; their efforts greatly enhanced the final product. We are particularly grateful for the assistance of Gail Burns Smith who, in addition to participating in focus groups and conference calls and submitting insightful comments on drafts, also was responsible for suggesting and organizing conference calls with victims to ensure the victim-centeredness of the protocol. i ii Foreword Sexual violence continues to plague our Nation and destroy lives. All members of society are vulnerable to this crime, regardless of race, age, gender, ability, or social standing. When sexual assault does occur, victims deserve competent and compassionate care. This second edition of the National Protocol for Sexual Assault Medical Forensic Examinations provides detailed guidelines for criminal justice and health care practitioners in responding to the immediate needs of sexual assault victims. We know that effective collection of evidence is of paramount importance to successfully prosecuting sex offenders. Just as critical is performing sexual assault forensic exams in a sensitive, dignified, and victim-centered manner. For individuals who experience this horrendous crime, having a positive experience with the criminal justice and health care systems can contribute greatly to their overall healing. As we have learned in the years since the implementation of the 1994 Violence Against Women Act, coordinated community efforts are the best way to stop violence against women, hold offenders accountable for their crimes, and promote victim healing and recovery. That is why this protocol was designed as a guide for practitioners who respond to victims of sexual assault, including health care professionals, law enforcement officers, prosecutors, interpreters, advocates, and others. Combining cutting edge response techniques with collaboration among service providers will greatly enhance our ability to treat and support victims as well as identify and prosecute the sex offenders. We hope that this protocol lays the foundation for these efforts. Since this protocol was initially released in 2004, the “state of the art” for forensic medical examinations has improved. This revised edition of the protocol has the same emphasis and values as the original but has been updated to reflect current technology and practice. It has also been updated to include additional information reflecting changes from the Violence Against Women Act of 2005. It also includes minor technical changes identified in May, 2013. iii iv Contents Goals ........................................................................................................... 1 Recommendations at a Glance ................................................................. 4 Introduction .............................................................................................. 12 Background .....................................................................................................................12 About this document ........................................................................................................13 Use of terms ....................................................................................................................14 Section A. Overarching Issues ............................................................... 21 1. Coordinated Team Approach Understanding the purpose of the exam ......................................................................... 23 Key responders and their roles ........................................................................................ 23 Quality assurance measures ........................................................................................... 26 2. Victim-Centered Care ............................................................................................. 29 Patient priority as an emergency case ............................................................................ 29 Patient privacy .................................................................................................................29 Exam adapted to patients’ needs and circumstances ..................................................... 30 Issues commonly faced by patients from specific populations ........................................ 31 Importance of victim services within the exam process ................................................... 39 Presence of personal support persons in the exam room ............................................... 41 Requests for a responder of a specific gender ................................................................ 41 Explanation of procedures during the exam process ...................................................... 41 Respect for patients’ priorities ......................................................................................... 41 Integration of medical and evidentiary collection procedures .......................................... 41 Patient safety during the exam process .......................................................................... 42 Information patients can review at their convenience ...................................................... 42 Physical comfort needs of patients .................................................................................. 42 3. Informed Consent .................................................................................................. 43 Seeking informed consent as appropriate ....................................................................... 43 Obtaining consent from specific populations ................................................................... 44 4. Confidentiality ........................................................................................................ 47 Scope and limitations of confidentiality ............................................................................ 47 Building understanding of confidentiality issues .............................................................. 47 Impact of federal privacy laws ......................................................................................... 48 Resolving intrajurisdictional conflicts ............................................................................... 49 5. Reporting to Law Enforcement ............................................................................. 51 Making the decision to report. ......................................................................................... 51 Consequences of reporting. ............................................................................................ 52 Alternatives to standard reporting procedures ................................................................. 53 Promoting a victim-centered reporting process ............................................................... 53 v 6. Payment for the Examination Under VAWA ........................................................ 55 VAWA provisions related to exam payment .................................................................... 55 Section B. Operational Issues ................................................................ 57 1. Sexual Assault Forensic Examiners ..................................................................... 59 Specific knowledge, skills, and attitudes ......................................................................... 59 Advanced education and clinical requirements ............................................................... 61 Access to experts ............................................................................................................61 2. Facilities .................................................................................................................. 63 Obligation to serve patients ............................................................................................. 63 Use of specially educated and clinically prepared examiners ......................................... 63 Optimal site locations ...................................................................................................... 64 Basic requirements .........................................................................................................64 Patient transfers ..............................................................................................................65 3. Equipment and Supplies ....................................................................................... 67 Availability of specific equipment and supplies ................................................................ 67 Cost barriers ....................................................................................................................68 4. Sexual Assault Evidence Collection Kit ..............................................................