April 2016 A National Protocol for Sexual Abuse Medical Forensic Examinations Pediatric A National Protocol for Sexual Abuse Medical Forensic Examinations Pediatric U.S. Department of Justice Office on Violence Against Women April 2016 NCJ # 249871 Table of Contents Acknowledgements ....................................................................................................................................... 1 Forward ......................................................................................................................................................... 3 Introduction .................................................................................................................................................. 5 A. Foundation for Response During the Exam Process ............................................................................... 21 A1. Principles of Care .............................................................................................................................. 23 A2. Adapting Care for Each Child ............................................................................................................ 31 A3. Coordinated Team Approach ............................................................................................................ 43 A4. Health Care Infrastructure ................................................................................................................ 55 A4a. Pediatric Examiners .................................................................................................................... 57 A4b. Facilities ...................................................................................................................................... 61 A4c. Equipment and Supplies ............................................................................................................. 67 A5. Infrastructure for Justice System Response During the Exam Process ............................................ 69 A5a. Reporting .................................................................................................................................... 71 A5b. Confidentiality and Release of Information................................................................................ 79 A5c. Evidentiary Kits and Forms .......................................................................................................... 83 A5d. Timing of Evidence Collection..................................................................................................... 87 A5e. Evidence Integrity ....................................................................................................................... 89 A5f. Payment Issues ............................................................................................................................ 93 B. Exam Process .......................................................................................................................................... 97 B1. Consent for Care ............................................................................................................................... 99 B2. Initial Response ............................................................................................................................... 105 B3. Entry into the Health Care System .................................................................................................. 109 B4. Written Documentation .................................................................................................................. 117 B5. Medical History ............................................................................................................................... 121 B6. Photo-Documentation .................................................................................................................... 129 B7. Examination .................................................................................................................................... 135 B8. Evidence Collection ......................................................................................................................... 149 B9. Sexual Abuse Facilitated by Alcohol and Drugs .............................................................................. 159 B10. Sexually Transmitted Disease Evaluation and Care ...................................................................... 165 B11. Discharge Planning and Follow-Up Care ....................................................................................... 175 Glossary and Acronyms ............................................................................................................................. 181 References ................................................................................................................................................ 191 Appendix 1. Tanner Stages of Sexual Maturation..................................................................................... 207 Appendix 2. Illustrations of Exam Positions and Techniques ................................................................... 209 Appendix 3. Labeled Diagrams of Genital Anatomy ................................................................................. 211 Appendix 4. Customizing a Community Protocol ..................................................................................... 213 Appendix 5. Impact of Crawford v. Washington and The Confrontation Clause ...................................... 215 Appendix 6. Initial Response Algorithm .................................................................................................... 219 Appendix 7. Care Algorithm ...................................................................................................................... 221 Appendix 8. Prepubescent STD Testing Algorithm ................................................................................... 223 Appendix 9. HIV Testing nPEP Algorithm .................................................................................................. 225 Appendix 10. Participants in Protocol Development ................................................................................ 227 Acknowledgements This protocol was the collaborative work of many experts in the field of pediatric sexual abuse as well as our federal partners. We would like to acknowledge and thank them for their time attending meetings, participating in conference calls, reviewing drafts, and otherwise providing input during the protocol development process. Special thanks goes to our partners at the IAFN, especially Diane Daiber, Kim Day, and Jennifer Pierce-Weeks. Particular appreciation also goes to Kristin Littel, who served as the primary writer and researcher for the protocol. We are grateful to everyone who generously gave their time and energy to support the success of this project. (See Appendix 10. Participants in Protocol Development) Note that the protocol borrowed from and built upon many excellent state, federal, national, tribal, and international resources, as well as research related to community response to child sexual abuse and pediatric sexual abuse medical forensic examinations. In particular, this protocol benefited from guidance offered in The Clinical Management of Children and Adolescents Who Have Experienced Sexual Violence: Technical Considerations for PEPFAR Programs (Day & Pierce-Weeks, 2013), Updated Guidelines for the Medical Assessment and Care of Children Who May Have Been Sexually Abused (Adams et al., 2015), and Medical Response to Child Sexual Abuse: A Resource for Professionals Working with Children and Families (Kaplan et al., 2011). It also adapted recommendations, where applicable, from the U.S. Department of Justice’s National Protocol for Sexual Assault Medical Forensic Examinations—Adults/Adolescents (2013). 1 2 Forward Sexual violence is a significant health, social, and legal problem in the United States. The U.S. Department of Justice, Office on Violence Against Women (OVW) strives to support communities across the country in their efforts to implement an effective response to victims of sexual violence. The medical forensic examination is an integral component of this response. It is designed to address victims’ health care needs and promote their safety and healing. In addition, forensic evidence collected during the examination—information gathered during the medical history, documentation of exam findings, and forensic samples, if potentially available—can help facilitate case investigation and prosecution of perpetrators of sexual violence. Success in meeting these objectives depends not only on the skills and knowledge of the health care providers conducting the examination, but also the coordinated efforts of all disciplines involved in the response to victims. With successful medical forensic care as a goal, OVW released the National Protocol for Sexual Assault Medical Forensic Examinations—Adults/Adolescents in 2004 and a second edition in 2013.1 It was evident during protocol development that the medical forensic care of adult and adolescent victims should be addressed separately from younger child victims, as considerable variations in approaches exist with these populations. OVW is pleased to now offer the National Protocol for Sexual Abuse Medical Forensic Examinations—Pediatric, which focuses on prepubescent children (see “Use of Terms” on page 8 for an explanation of terms used in this protocol).