Recommendations at a Glance: A National Protocol for Sexual Assault Medical Forensic Examinations

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The National Protocol for Sexual Assault Medical Forensic Examinations offers guidance to jurisdictions in creating and implementing their own protocols, as well as recommending specific procedures related to the exam process. Recommendations at a Glance highlights key points discussed in the protocol, but it is not designed to be a stand-alone checklist on exam procedures or responsibilities of each involved responder. The protocol should be read to understand and respond to the complex issues presented during the exam process. See the protocol introduction for an explanation of select terms used in this chapter and the protocol.

Goal of the Protocol

A timely, high-quality medical forensic examination can potentially validate and address sexual assault patients’1 concerns, minimize the trauma they may experience, and promote their healing. At the same time, it can increase the likelihood that evidence collected will aid in criminal case investigation, resulting in perpetrators being held accountable and further sexual violence prevented.

The examination and the related responsibilities of health care personnel are the focus of this protocol. Recognizing that multidisciplinary coordination is vital to the success of the exam, the protocol also discusses the responses of other professionals, as they relate to the exam process.

A. Overarching Issues

1. Coordinated approach: A coordinated, multidisciplinary approach to conducting the exam provides victims2 with access to comprehensive immediate care, helps minimize trauma they may experience, and encourages their use of community resources. Such a response can also enhance public safety by facilitating investigation and prosecution, which increases the likelihood that offenders will be held accountable for their actions. Raising public awareness about the existence and benefits of a coordinated response to sexual assault may lead more victims to disclose the assault and seek help.
Recommendations for jurisdictions to facilitate a coordinated approach to the exam process:

  • Understand that the purposes of the exam process are to address patients’ health care needs and collect evidence suitable for possible use by the criminal justice system.
  • Identify key responders and their roles.
  • Develop quality assurance measures to ensure effective response during the exam process.

2.Victim-centered care: Victim-centered care is paramount to the success of the exam process. Response to victims should be timely, appropriate, sensitive, and respectful.

Recommendations for health care providers and other responders to facilitate victim-centered care:

  • Give sexual assault patients priority as emergency cases.
  • Provide the necessary means to ensure patient privacy.
  • Adapt the exam process as needed to address the unique needs and circumstances of each patient.
  • Develop culturally responsive care and be aware of issues commonly faced by victims from specific populations.
  • Recognize the importance of victim services within the exam process.
  • Accommodate patients’ requests to have a relative, friend, or other personal support person (e.g., religious and spiritual counselor/advisor/healer) present during the exam, unless considered harmful by responders.
  • Accommodate patients’ requests for responders of a specific gender throughout the exam as much as possible.
  • Prior to starting the exam and conducting each procedure, explain to patients in a language the patients understand what is entailed and its purpose.
  • Assess and respect patients’ priorities.
  • Integrate medical and evidentiary procedures where possible.
  • Address patients’ safety during the exam.
  • Provide information that is easy for patients to understand, in the patient’s language, and that can be reviewed at their convenience.
  • Address physical comfort needs of patients prior to discharge.

3.Informed consent: Patients should understand the full nature of their consent to each exam procedure. By presenting them with relevant information, in a language they understand, patients are in a position to make an informed decision about whether to accept or decline a procedure. However, they should be aware of the potential impact of declining a particular procedure, as it may negatively affect the quality of care, the usefulness of evidence collection, and, ultimately, any criminal investigation and/or prosecution. They should understand that declining a particular procedure might also be used against them in any justice system

proceeding. If a procedure is declined, reasons why should be documented if the patient provides such information.

Recommendations for health care providers and other responders to request patients’ consent during the exam process:

  • Seek the informed consent of patients as appropriate throughout the exam process.
  • Make sure policies exist to guide the process of seeking informed consent from specific populations.

4.Confidentiality: Involved responders must be aware of the scope and limitations of confidentiality related to information gathered during the exam process. Confidentiality is intricately linked to the scope of patients’ consent. Members of a sexual assault response team (SART) or other collaborating responders should inform victims of the scope of confidentiality with each responder and be cautious not to exceed the limits of victim consent to share information in each case.

Recommendations that jurisdictions may take to maintain confidentiality of patients:

  • Be sure jurisdictional policies address the scope and limitations of confidentiality as it relates to the exam process and with whom information can be legally and ethically shared.
  • Increase the understanding of relevant confidentiality issues. .
  • Consider the impact of the federal privacy laws regarding health information on victims of sexual assault.
  • Strive to resolve intrajurisdictional conflicts.

5. Reporting to law enforcement: Reporting the crime provides the criminal justice system with the opportunity to offer immediate protection to victims, collect evidence from all crime scenes, investigate cases, prosecute if there is sufficient evidence, and hold offenders accountable for crimes committed. Given the danger that sex offenders pose to the community, reporting can serve as a first step in efforts to stop them from reoffending. Equally important, reporting gives the justice system the chance to help victims address their needs, identify patterns of sexual violence in the jurisdiction, and educate the public about such patterns. Service providers should discuss all reporting options with victims in a language they understand and the pros and cons of each, including the fact that delayed reporting may be detrimental to the prosecution of an offender. Even if a victim does not get a forensic medical exam, the victim can still report the crime at a later time. However, it will be much more difficult for criminal justice personnel to investigate and prosecute the crime if evidence was not collected.

Reporting requirements in sexual assault cases vary from one jurisdiction to another. Every effort should be made to facilitate treatment and evidence collection (if the patient agrees), regardless of whether the decision to report has been made at the time of the exam. Victims who are undecided about reporting who receive respectful and appropriate care and advocacy at the time of their exam are more likely to assist law enforcement and prosecution. Because immigrant victims may be more reticent to report crimes, they need to be aware of crime victim protections for immigrants. Access to immigration relief for crime victims will enhance the ability of law enforcement to detect, investigate, and prosecute crimes.

Recommendations for jurisdictions and responders to facilitate victim-centered reporting practices:

  • Except in situations covered by mandatory reporting laws, patients, not health care workers, make the decision to report a sexual assault to law enforcement.
  • Inform patients about reporting consequences.
  • As a result of VAWA 2005, many jurisdictions have implemented alternatives to standard reporting procedures.
  • Promote a victim-centered reporting process.

6.Payment for the examination under VAWA: Under the Violence Against Women Act (VAWA),3 a state, territory, or the District of Columbia is entitled to funds under the STOP Violence Against Women Formula Grant Program only if it, or another governmental entity, incurs the full out-of-pocket cost of medical forensic

exams for victims of sexual assault. “Full out-of-pocket costs” means any expense that may be charged to a victim in connection with the exam for the purpose of gathering evidence of a sexual assault.4 In addition, under the Violence Against Women Act of 2005, states may not require victims to participate in the criminal justice system or cooperate with law enforcement in order to receive a forensic medical exam.5

Recommendations for jurisdictions to facilitate payment for the sexual assault medical forensic exam:

  • Understand the scope of the VAWA provisions related to exam payment.
  • Notify victims of exam facility and jurisdictional policies regarding payment for medical care and the medical forensic exam.

Go to the next section- Recommendations at a Glance- Operational Issues

1 Sexual assault patients are also referred to as victims, depending on which responders are primarily being discussed. The term “patients” is generally used by health care professionals.

2 The term “victim” is not used in a strictly criminal justice context. The use of “victim” simply acknowledges that persons who disclose that they have been sexually assaulted should have access to certain services.

3 42 U.S.C. § 3796gg-4.

4 28 C.F.R. § 90.14(a).

5 42 U.S.C. 3796gg-4(d).