Glossary and Acronyms
Many terms and acronyms are explained and used throughout the protocol. However, it is helpful to have a reference tool to turn to for an explanation of terms and acronyms used. Note this section is not an exhaustive list of terms pertinent to the exam process or of commonly used acronyms. Also, explanations are listed here as they apply to this protocol and may vary from those used in protocols developed by states, territories, tribes, federal agencies, and/or local communities.
See www.SAFEta.org for medical and forensic definitions.
ADOLESCENTS: As defined in this document, adolescents are children who are Tanner stage 3 and above who have potential reproductive capability (see TANNER STAGES below and Appendix 1. Tanner Stages of Sexual Maturation). A Tanner stage 3 or 4 biological female, even if premenarchal, potentially has reproductive capacity. Adolescent victims as defined here are NOT addressed in this protocol, but in the adult/adolescent protocol available at www.ncjrs.gov/pdffiles1/ovw/241903.pdf.
ASSENT: The expressed willingness to participate in an activity (e.g., exam procedures). For younger children who are by definition too young to give informed consent to care, but old enough to understand and agree to participate, the child’s informed assent is sought. (IRC, 2012).
CAREGIVER: A person exercising a day-to-day caregiver role for a child, such as a parent, guardian, foster parent, sibling, relative, or family friend. Caregivers may or may not have legal responsibility for the child. Additional persons may play a +more temporary caregiver role for a child, such as a child care provider or babysitter. (Adapted from Day & Pierce-Weeks, 2013; IRC, 2012; WCSAP, 2009).
CHAIN OF CUSTODY: A formal, chronological documentation of the custody and possession of evidence. It is used to establish the integrity of the evidence collection in a court of law.
CHILD DEVELOPMENT: Refers to how a child becomes able to do more complex tasks, as they get older, with a focus on gross and fine motor, language, cognitive, and social skills (University of Michigan Health System, 2015). In addition to physical growth, children typically experience distinct periods of development as they age. For information on developmental milestones, see the CDC (2015c) at www.cdc.gov/ncbddd/childdevelopment/facts.html.
CHILD-FOCUSED: In this document, refers to an approach to care that is developmentally, linguistically, and culturally appropriate for prepubescent children, designed with their needs and best interest in mind, and intended to reduce potentially traumatic effects of the exam process.
CHILD SEXUAL ABUSE (WHO, 1999): Child sexual abuse, as used in this protocol, is intended to encompass any sexual violence a prepubescent child may experience. Specifically, it refers to the involvement of a child in sexual activity that she/he does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society (WHO, 1999). Child sexual abuse can occur between a child and a person or persons of any age or relationship to the child. The intent of the abuse is to gratify or satisfy the needs of the other person(s) (WHO, 1999). (See the Introduction for a discussion on the nature of child sexual abuse acts). Note that the term “child sexual abuse” often has different meanings across jurisdictions and clinical settings.
CHILDREN: A child is anyone under 18, unless majority [adulthood] is attained earlier under the applicable law of a jurisdiction (e.g., those pertaining to age of consent, child protection, and criminal responsibility) (UN Office of the High Commissioner for Human Rights, 1989). There is some variation across U.S. states regarding the age of majority—see http://minors.uslegal.com/age-of-majority/ for information on related laws of each state. Note this document addresses only prepubescent children.
CHILDREN’S ADVOCACY CENTER: Children’s advocacy centers have been established in many jurisdictions to facilitate multidisciplinary team coordination in child abuse and neglect cases, with the goals of child safety, trauma-informed care, justice, and healing. These centers are child-friendly facilities in which a multidisciplinary team of professionals (typically comprised of law enforcement officials, child protective services, prosecutors, medical professionals, mental health providers, and victim advocates) coordinate the investigation, prosecution, child protection, and treatment of child abuse. In addition to brokering coordination among responders in individual cases, many children’s advocacy centers offer a location to provide services to children under one roof, such as forensic interviews, medical forensic examinations, victim advocacy, and mental health treatment.
CHILD PROTECTIVE SERVICE REPRESENTATIVE: An agent of the local, state, tribal, or federal government who is responsible for the assessment of risk to the child who may have been abused and to the child’s siblings. The assessment is often coordinated with law enforcement authorities. The child protective service representative has jurisdiction over the protection, placement, and long-term disposition of the child, as well as services and support for the victim’s family. In this protocol, personnel from child protective service agencies are referred to as child protective service workers or child protective service representatives, unless more specificity is required. In some jurisdictions, child protective service agencies are mandated to participate in multidisciplinary response teams that investigate child abuse and neglect.
CONFIDENTIALITY: An ethical principle associated with medical and social services professions. Maintaining confidentiality requires that providers protect information gathered about patients/clients and agree only to share information about a patient/client’s case with their explicit permission. All written or photo-documentation from a child sexual abuse case should be maintained in a confidential place in locked or secure files. Significant limits to confidentiality exist while working with prepubescent children who have been sexually abused. In some jurisdictions, mandatory reporting laws may override health privacy laws and require sharing of information among investigative agencies. Note that confidentiality is distinguished from privileged communication, which is a legal protection of certain information. Privilege laws are jurisdiction-specific, but often include medical providers, mental health providers, and community-based victim advocates. However, as with confidentiality, privileged communication is limited in child sexual abuse cases.
CONTACT CHILDREN: All the children that may have had contact with the alleged perpetrator. Contact children include siblings, relatives, or any other child that the alleged perpetrator can access. They should be considered for medical forensic care and reported to legal authorities.
CULTURE: Generally speaking, a body of learned beliefs, traditions, and guides for behaving and interpreting behavior that is shared among members of a particular group (Blue, n.d.). Aspects of a culture include its values, beliefs, customs, communication styles, behaviors, practices, and institutions (Blue, n.d.).
CULTURAL GROUP: In this protocol, this refers not only to ethnic or racial groups, but also to other groups with distinct cultures. Examples include faith communities; Deaf and hard-of-hearing communities; children with other disabilities; populations with differing sexual orientations and gender identities or expressions; immigrants; refugees; the homeless; military personnel and their dependents; and individuals in correctional settings, foster care systems, boarding schools, and other residential settings. One culture may be closely connected to another (e.g., an ethnic group may be rooted in religious and/or spiritual beliefs of a particular faith community). Individuals often belong to multiple cultural groups. Note that cultural beliefs may or may not affect a child’s experience of sexual abuse, the related reactions of the child and caregiver, and their preferred approaches to emotional support, healing, and justice (adapted from DeBoard-Lucas et al., 2013). If culture is influential in this regard, responders can offer to help children and caregivers access cultural resources during the exam process and beyond.
DISABILITY (CDC, 2015b): There are many types of disabilities, such as those that affect vision, movement, thinking, remembering, learning, communicating, hearing, mental health, and social relationships. Disabilities can affect children in different ways, even if one child has the same type of disability as another child. Some disabilities may be hidden or not easy to see. Disability can occur at any point in a child’s life (e.g., an infant can be born with spina bifida, which may affect walking; a child could be in a motor vehicle accident and have traumatic brain injury, which may affect thinking and remembering; a child can have mental illnesses which may make it difficult to manage day-to-day stressful situations; a child may be born with or develop hearing or vision loss, which may affect communication; or a child may have a developmental disability, such as autism, which can affect social interactions, communications, and behavior).
DISCLOSURE: The process of revealing information. In reference to this document, disclosure refers specifically to how a person learns about a child’s experience with sexual abuse. Disclosure about sexual abuse can be directly or indirectly communicated, voluntarily or involuntarily.
EVIDENCE COLLECTION KIT: In this document, refers to a box or envelope that outlines specific types of forensic evidence requested by a jurisdictional crime lab from the body of a victim of sexual violence. It contains the necessary materials for collection, packaging, and maintaining chain of custody once the evidence is gathered, packaged, and sealed. The kit may also be referred to as an evidentiary kit in this document.
EVIDENCE-INFORMED (adapted from National Collaborating Centre for Methods and Tools, 2012): As used in this document, refers to the process of distilling the best available evidence from research, context, and experience, and then using that evidence to inform and improve policy. Evidence-informed decision making considers evidence from a variety of sources: an understanding of related community issues and local context; existing related resources; community and political climate; and the best available research findings. (Note this definition comes from a public health source, but is generally applicable to policy making related to the sexual abuse medical forensic exam process)
EXAM FACILITY: The site at which the child sexual abuse medical forensic examination is conducted.
EXAM PROCESS: In this document, refers to the child’s entry into the health care system, the medical forensic examination in its entirety, and planning at the exam’s conclusion to facilitate post-exam health care and referrals to address child-, family-, and case-specific needs.
FIRST/INITIAL RESPONDER: A professional who initially responds to a disclosure of child sexual abuse (there is often more than one first responder). These professionals typically follow agency/facility response policies. Those who traditionally have been responsible for immediate response to child sexual abuse include child protective service workers, 911 dispatchers, law enforcement representatives, health care providers, children’s advocacy center staff, and victim advocates. A wide range of other responders also may be involved, such as emergency medical service providers, paramedics, public safety officials, prosecutors and victim—witness staff, mental health providers, social service workers, corrections and probation staff, spiritual support persons, child care providers, school personnel, employers, certified interpreters, and providers from organizations that address needs of specific populations (e.g., persons with disabilities, racial and cultural groups, the homeless, runaways, adolescents in foster care, domestic violence victims, and persons who identify as LGBTI). Families and friends of victims can play an important role in the initial response; however, they are not considered first responders in this document.
FORENSIC EVIDENCE: Information, objects, or specimens that may be admitted into court for judges and juries to consider when hearing a case. Forensic evidence may come from a variety of sources, including biological sources.
FORENSIC SCIENTIST: The forensic scientist is responsible for analyzing evidence in sexual abuse cases. This evidence typically includes DNA and other biological evidence, toxicology samples, latent prints, and trace evidence. Some forensic scientists specialize in the analysis of specific types of evidence. In this protocol, forensic scientists working in jurisdictional crime laboratories may be referred to as crime lab/laboratory personnel. Forensic scientists analyzing drug and alcohol samples are also referred to as toxicologists. Forensic scientists in some communities may respond to crime scenes to collect evidence and to process the scene.
JURISDICTION: A community that has power to govern or legislate for itself. For example, a jurisdiction may be a local area, state, territory, or tribe. Jurisdiction also describes the authority to interpret and apply laws—it is used in this context when identifying who has jurisdiction over a particular case.
INFORMED CONSENT: Refers to explaining all aspects of the exam process to the prepubescent child and her/his parents/guardian (as applicable), in a manner they can fully understand. When working with children, keep in mind that the explanation must be developmentally appropriate. It is crucial that child patients and their parents/guardians are aware of the options open to them and given sufficient information to enable them to make informed decisions about care during the exam process. Even if the child cannot legally give consent, she/he can still give informed assent.
LANGUAGE ASSISTANCE SERVICES: Oral language services for interpretation and written language services, including translation of written materials into languages other than English for limited English proficient (LEP) individuals.
LAW ENFORCEMENT REPRESENTATIVE: Different types of law enforcement agencies exist at the local, state, territory, tribal, and federal levels (e.g., state, county, tribal, or local police or sheriff, sworn police on college campuses, the FBI, the Bureau of Indian Affairs (BIA), and military police). Any of these agencies could potentially be involved in responding to child sexual abuse cases. Also, in areas without a local law enforcement agency, public safety officials may assist in immediate response to child sexual abuse. Some agencies may have staff with specialized education and experience in child sexual abuse who may be dedicated to investigating sexual abuse cases and/or part of special units for investigating child sexual abuse. Dedicated staff and special units may more broadly address child abuse and neglect. In this protocol, personnel from law enforcement agencies are referred to as law enforcement officers or law enforcement representatives, unless more specificity is required. Some are mandated to participate in jurisdictional multidisciplinary response teams that investigate child abuse and neglect.
LIMITED ENGLISH PROFICIENT (LEP): Refers to individuals who do not speak English as their primary language and have a limited ability to read, speak, write, or understand English. LEP individuals may be entitled to language assistance services to ensure they have meaningful access to a benefit, program, or service that receives federal financial assistance.
LOCARD’S EXCHANGE PRINCIPLE: A principle of forensic science, developed by Edmund Locard, in which he found that every contact, no matter how slight, between two items will result in an exchange between the two. Any contact between a perpetrator and child, as well as the crime scene itself, may have potential corroborating evidence left behind (trace materials and/or body fluids from the perpetrator). As the body of the child is assessed, forensic samples should be taken from the areas where potential evidence may exist.
MEDICAL FORENSIC EXAMINATION: In this document, refers to an examination of a prepubescent child who has disclosed or is suspected of being sexually abused. It is conducted by a health care provider, ideally one who has specialized education and clinical experience in the collection of forensic evidence and treatment of pediatric patients who have been sexually abused. The examination includes: evaluating the child for acute care needs; gathering information from the child and her/his caregiver, as appropriate, for the medical history; a physical and anogenital examination; coordinating treatment of injuries; documentation of exam findings; collection of forensic samples from the child, when applicable; information, testing, treatment, and referrals for STDs (including HIV); assessment of suicidal ideation and other nonacute medical concerns; and follow-up as needed to provide additional healing, treatment, or collection of forensic evidence. It is also essential during the exam process for the health care provider conducting the examination to coordinate with other involved responding entities to ensure that any concerns regarding the child’s safety that are identified in the course of the examination are addressed, as well as to offer emotional support, crisis intervention, education, and advocacy to children and their caregivers, as needed.
MANDATORY REPORTING: Refers to jurisdictional laws and policies, which mandate certain agencies and/or persons in helping professions (teachers, social workers, health staff, etc.) in that jurisdiction to report to child protection and/or criminal justice authorities actual or suspected child abuse (e.g., physical, sexual, neglect, emotional and psychological abuse, unlawful sexual intercourse). Some jurisdictional laws require all citizens to report child sexual abuse.
MULTIDISCIPLINARY RESPONSE TEAM: Refers to a multidisciplinary team response to child sexual abuse that seeks to foster coordination and communication among those agencies/facilities in a community that respond to child sexual abuse. This protocol focuses on the multidisciplinary team response related to the exam process. A team structure provides a mechanism to link key entities and allows them to consistently coordinate their interventions whenever there is a report, disclosure, or suspicion of child sexual abuse. It also helps them communicate about what is happening in individual cases. The team structure is a quality assurance mechanism, promoting regular meetings of responders, case review, education, and activities to prevent vicarious trauma. Jurisdictions vary in the extent and formality of team coordination, as well as in team purposes, and may refer to these teams by a variety of names. In many jurisdictions, multidisciplinary teams are statutorily mandated to coordinate all child abuse and neglect investigations. The development of coordination protocols to guide their response is also often required.
Note that teams should include MULTIJURISDICTIONAL representation if cases typically involve responding entities from more than one jurisdiction.
PEDIATRIC (adapted from Stanton & Behrman, 2011): Generally concerned with all aspects of the wellbeing of children. Note the pediatric population addressed in this protocol is solely prepubescent children as described below. Pediatric health care must be concerned with particular organ systems and biological processes, developmental issues, and environmental and social influences that affect the health and wellbeing of children and families.
PEDIATRIC EXAMINER: Refers to the health care provider conducting the pediatric sexual abuse medical forensic examination. Jurisdictions across the country rely on a range of health care providers (e.g., physicians, registered nurses, and advanced practice providers, such as advanced practice nurses and physician assistants) who have been specially educated and completed clinical requirements to provide medical forensic care for prepubescent children. Communities may refer to their trained pediatric examiners by specific terms and acronyms based upon the discipline of practitioners and/or specialized education and clinical experiences.
PERPETRATOR: In this document, refers to a person who directly inflicts or supports sexual abuse of prepubescent children. Perpetrators may be adults or children who have power over the victim, including caregivers; other family members living in the home; nonresident relatives (e.g., uncles/aunts, grandparents, cousins); friends, acquaintances, and neighbors (of the family but also the child’s peers); strangers; and authority figures (e.g., teachers, spiritual leaders, health care workers, youth group leaders, and adults from organizations that work with children). The suspected perpetrator may be referred to in this protocol as a suspect. When litigation is discussed, the suspected perpetrator may be referred to as a defendant. When talking more broadly about perpetrators, they may also be referred to as offenders or assailants.
PREPUBESCENT: A child’s stage of pubertal development is determined by assessing secondary sexual characteristics rather than chronological age. Although the onset and timeline of the pubertal process is unique to each child, the stages are identifiable and predictable (Fritz & Speroff, 2011; Jenny, 2011; Kaplowitz et al., 1999). Tanner stages detail the physical signs of breast, pubic hair, and male genitalia development for each of the five sexual maturation stages (see Appendix 1. Tanner Stages of Sexual Maturation). Prepubescent children’s sexual characteristic development is reflected as stage 1 or stage 2 of Tanner stages (Child Growth Foundation, n.d.; Marshall & Tanner, 1969). Prepubescent children require interventions during the medical forensic examination that are tailored to their developmental stage. In addition, these interventions must be based on population-specific knowledge of differences between normal variants and healed injuries from prior abuse. Note that while the onset of puberty should not be correlated to a chronological age, concerns about precocious or delayed sexual development should be referred to the appropriate pediatric specialist.
PROSECUTOR: Different types of prosecution offices exist at the local, tribal, state, territory, and federal level (e.g., tribal prosecutor’s office, county prosecutor’s office, district attorney’s office, state attorney’s office, United States Attorney’s office, and military judicial branches). Any of these offices could be involved in responding to child sexual abuse. In addition, some offices may have personnel with specialized education and experience in child sexual abuse who may be dedicated to prosecuting child sexual abuse, or more broadly, child abuse and neglect and/or part of special units with the same goal. In this protocol, attorneys from prosecution offices will be referred to as prosecutors unless more specificity is required. Some are mandated to participate in jurisdictional multidisciplinary response teams that coordinate child abuse and neglect investigations.
SEXUALLY TRANSMITTED DISEASE (STD): The term refers to a variety of clinical syndromes and infections caused by pathogens that can be acquired and transmitted through sexual activity (CDC, 2015). Although the term STD is used in this protocol, STDs are also commonly referred to as sexually transmitted infections (STIs). See the American Sexual Health Association (2015) at www.ashasexualhealth.org/stdsstis/ for related discussion.
TANNER STAGES: A scale of physical measurements of development, based on external primary and secondary sex characteristics. The scale was first identified by James Tanner, a British pediatrician. Tanner staging characterizes a scale from 1 to 5, based on secondary sex organ development. Considered in the scale for girls is development of breasts and pubic hair, and for boys is testicular volume and pubic hair. The scale was developed with reference to a single ethnic group and a relatively small sample of only 200 children, so using this as a measure may not apply to all ethnic groups. (Blackemore, Burnet, & Dahl, 2010). Different ethnic groups may have variations in breast development, pubic hair growth, distribution, or growth patterns. Care should be taken to assess children for pubertal development based on knowledge of local ethnic variations and common characteristics. (See Appendix 1. Tanner Stages of Sexual Maturation)
TRAUMA-INFORMED: In this document, refers to an approach to care that seeks to support the healing and growth of children who have experienced sexual abuse, while avoiding their retraumatization (RSP & NSVRC, 2013). It considers and evaluates all interventions in light of a basic understanding of the role that sexual abuse plays in the lives of child victims (Harris & Fallot, 2001; RSP & NSVRC, 2013). It integrates an understanding of the victim’s history and the entire context of their experience. It recognizes the effects that trauma can have on the child’s behavior, coping strategies, relationships, and ability to interact with health care providers, law enforcement, and other professionals involved.
URGENCY OF MEDICAL FORENSIC CARE: In this document, this phrase refers to whether the need for medical forensic care is acute versus nonacute. Generally, an ACUTE EXAMINATION should be conducted within the time frame prescribed by the jurisdiction for the collection of forensic samples, if there is a possibility of evidence on the child’s body or clothing OR if there are factors beyond that time frame that indicate acute medical forensic care is necessary. In most jurisdictions, a child is referred for a NONACUTE EXAMINATION if the abuse occurred beyond the jurisdictional time frame for an acute examination AND there is no indication for acute medical forensic care. The protocol directs health care providers, rather than law enforcement or child protective service representatives, to determine the type of care appropriate for a child. (See B3. Entry into the Health Care System)
VICTIM: This protocol focuses on prepubescent child victims of sexual abuse. The victim can be a female or male, a person whose gender identity does not conform to her/his biological sex, or someone who does not identify as either female or male. In many instances, prepubescent children do not actually disclose that they have been abused. Individuals who suspect sexual abuse may seek help for these children. Note that because the protocol addresses a multidisciplinary team response, the term “victim” is not used in a strictly criminal justice context. The use of this term simply acknowledges that children in sexual abuse cases should have access to certain services and interventions designed to help them be safe, recover, and seek justice. The terms “victim,” “survivor, “and “patient” are used interchangeably.
VICTIM ADVOCATE: A victim advocate typically can offer child sexual abuse victims and their family members a range of services before, during, and after the exam process. These services may include support, crisis intervention, information and referrals, counseling, and advocacy to ensure the child’s interests are represented, their wishes respected, and their rights upheld. In addition, victim advocates may provide follow-up services, such as support groups, counseling, accompaniment to related appointments (e.g., medical and legal), and legal advocacy (civil, criminal, and immigration) to help meet the needs of victims and their families. Numerous types of victim advocacy agencies may offer some or all of these services, including: community-based sexual assault victim advocacy programs; children’s advocacy centers (see explanation above); criminal justice system victim-witness offices at the local, state, territorial, tribal, and federal levels; military family advocacy programs; tribal social services, and others. In some communities, patient advocate programs at health care facilities also may be enlisted to provide some of these services when a child victim is a patient.
Note that criminal justice system based advocates/victim service providers, such as those in law enforcement or prosecution offices, generally cannot offer confidential services, while community-based advocates/victim service providers generally can (to the extent permissible by jurisdictional law and their program policies).
VICTIM-CENTERED: In this document, refers to an approach to care that is grounded in an awareness of and commitment to addressing the needs of child victims of sexual abuse during the exam process. It recognizes that child victims deserve timely, compassionate, respectful, and appropriate care to promote their healing, as well as information to allow decision making. Care is informed by the child’s circumstance. Medical personnel may refer to this as patient-centered care.
Acronyms Used in the Protocol
ALS alternate light source
ASL American Sign Language
CT C trachomatis
GHB gamma hydroxy butyrate
HBV hepatitis B virus
HIV human immunodeficiency virus
HPV human papillomavirus
HSV herpes simplex virus
HIV nPEP human immunodeficiency virus nonoccupational post-exposure prophylaxis
LEP limited English proficient
LGBTI lesbian, gay, bisexual, transgender, and/or intersex
MOU memorandum of understanding
MOA memorandum of agreement
NAAT nucleic acid amplification test
NG N gonorrhea
PTSD post-traumatic stress disorder
SANE sexual assault nurse examiner
SAFE sexual assault forensic examiner
SART sexual assault response team
STD sexually transmitted disease
TV T vaginalis
ADA Americans with Disabilities Act
EMTALA Emergency Medical Treatment and Labor Act
HIPAA Health Insurance Portability and Accountability Act
HITECH Health Information Technology for Economic and Clinical Health Act
PREA Prison Rape Elimination Act
VAWA Violence Against Women Act
AAP American Academy of Pediatrics
AHIMA American Health Information Management Association
CALiO National Children’s Advocacy Center’s Child Abuse Library Online
CDC Centers for Disease Control and Prevention
DoD U.S. Department of Defense
DOJ U.S. Department of Justice
FBI Federal Bureau of Investigation
IAFN International Association of Forensic Nurses
IRC International Rescue Committee
NCA National Children’s Alliance
NSVRC National Sexual Violence Resource Center
OJJDP Office on Juvenile Justice and Delinquency Programs
OVW Office on Violence Against Women
OVC Office for Victims of Crime
RSP National Sexual Assault Coalition Resource Sharing Project
SAFEta Sexual Assault Forensic Examination Technical Assistance
WCSAP Washington Coalition of Sexual Assault Programs
WHO World Health Organization
 Also see the American Professional Society on the Abuse of Children (1995) and Technical Working Group on Biological Evidence Preservation (2013) for two resources for explanation of medical and forensic terms.
 Child sexual abuse acts do not encompass developmentally appropriate sexual behaviors of children, as described in B3. Entry into the Health Care System.
 To search for child sexual abuse definitions by state and territory, see Child Welfare Information Gateway at www.childwelfare.gov/topics/systemwide/laws-policies/state/.