is performing sexual assault forensic exams in a sensitive, dignified, formula-faq.pdf for more information on the STOP Formula Grant Program medical
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i 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 prot ocol.
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iii 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 prac titioners 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 w e have learned in t he 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 co llaboration 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 rel eased in 2004 , the ﬁstate of the artﬂ 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.
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v Contents Goals .. 1 Recommendations at a Glance .. 4 Introduction . 12 Background 12 About this document .. 13 Use of terms .. 14 Section A. Ove rarching 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 Physi cal 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 l imitations 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
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vii Immediate medical and mental health interventions . 84 3. Documentation by Health Care Personnel .. 85 Completion . 85 Education for examiners .. 85 Mechanisms to ensure accuracy and objectivity . 85 4. The Medical Forensic History . 87 Coordination of history taking and investigative interviewing 87 Presence of advocates during the history .. 87 Patient needs addressed prior to and during history . 88 Obtaining the history .. 88 5. Photography .. 91 Extent 91 Photographers and equipment . 91 Patient comfort and privacy .. 91 Explanation of photography procedures . 92 Initial and follow -up photographs . 92 Photograph storage 93 6. Exam and Evidence Collection Procedures .. 95 Evidentiary purpose of the exam . 95 Collecting as much evidence as possible 95 Issues related to consent to sexual contact 95 Testing of biological evidence .. 96 Exposure to infectious materials and evidence contamination . 96 Importance of semen evidence 97 Addressing patients™ needs and concerns .. 97 Explanation of exam and evidence collection procedures .. 97 Conducting the exam and documenting findings . 97 Evidence to submit to the crime lab for analysis . 98 Other evidence .. 105 Medical specimens separate from forensic specimens . 105 7. Alcohol and Drug -Facilitated Sexual Assault . 107 Training and development of policies . 1 07 Response to voluntary use of drugs and/or alcohol 107 Circumst ances in which testing may be indicated 1 08 Explanation of testing procedures 1 08 Collecting samples .. 1 09 Toxicology labs .. 110 Preservation of evidence and chain of custody . 1 10 8. STI Evaluation and Care .. 111 Information on STIs . 111 STI testing 1 11 Prophylaxis against STIs .. 1 12 Follow -up care 1 12 Concerns about HIV infection . 1 13
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viii 9. Pregnancy Risk Evaluation and Care .. 115 Probability of pregnancy 115 Pregnancy testing . 115 Treatment options . 115 Facility policy .. 1 16 10. Discharge and Follow -up .. 117 Medical discharge and follow -up care 117 Coordination among responders prior to discharge 118 11. Examiner Court Appearances . 121 Broad education on court appearances . 121 Prompt notification for examiners . 122 Pretrial preparation .. 122 Feedback on testimony . 123 Bibliography .. 125 Appendix A. Developing Customized Protocols: Considerations for Jurisdictions . 129 Appendix B. Creation of Sexual Assault Response and Resource Teams 133 Appendix C. Impact of Crawford v. Washington , Davis v. Washi ngton and Giles v. California 135
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1 Goals of the National Protocol for Sexual Assault Medical Forensic Examinations Sexual assault is a crime of violence against a person™s body and will. Sex offenders use physical and/or psychological aggression or coercion to victimize, in the process often threatening a victim™s sense of privacy, safety, autonomy, and well -being. Sexual assault can result in physical trauma and significant mental anguish and suffering for victims. In some communities, sexual violence is considered a form of oppression. Victims may be reluctant, however, to report the assault to law enforcement and to seek medical attention for a variety of reasons. For example, victims may blame themselves for the sexual assault and feel embarrassed. They may fear their assailants or worry about whether they will be believed. Victims may also lack the ability or emotional strength to access services. For example, they may not have their own transportation or access to public transportation. They may also not speak English well or fear that reporting the assault may jeopardize their immigration status .1 They may lack health insurance and believe it would be too costly to get the medical care they need. They may not be aware that as a crime victim, they are eligible for financial reimbursements for certain services. Their budgets may not allow them to pay out -of-pocket expenses and then await reimbursements. Those who do have access to services may perceive the medical forensic examination as yet another violation because of its extensive and intrusive nature in the immediate aftermath of the assault. Rather than seek assistance, a sexual assault victim may simply want to go somewhere safe, clean up, and try to forget the assault ever happened. 2 It is our hope that this protocol will help jurisdictions in their efforts to respond to sexual assault victims in the most competent, compassionate, and understanding manner possible. This protocol was developed with the input of national, local, and tribal experts throughout the country, including law enforcement representatives, prosecutors, advocates, medical personnel, forensic scientists, and others. We hope that this protocol will be useful in helping jurisdictions develop a response that is sensitive to victims of sexual assault and that promotes offender accountability. Specifically, the protocol has the following goals: Supplement , but not supersede , the many excellent protocols that have been developed by states, tribes, and local jurisdictions, as well as those created at the national level. We hope that this protocol will be a useful tool for jurisdictions wishing to develop new protocols or revise their existing ones. It is intended as a guideline for suggested practices rather than a list of requirements. In many places, the protocol refers to ﬁjurisdictional policiesﬂ because there may be multiple valid ways to handle a particular issue and which one is best should be determined by the jurisdiction after consideration of local laws, policies, practices, and needs. Provide guidance to jurisdictions on responding to adult and adolescent victims. Adolescents are distinguished in the protocol from prepubertal children who require a pediatric exam. Pediatric exams are not addressed in this document. This protocol generally focuses on the examination of females who have experienced the onset of menarche and males who have reached puberty. Legally, jurisdictions vary in the age at which they consider individuals to be minors, laws on child sexual abuse, mandatory reporting policies for sexual abuse and assault of minors, instances when minors can consent to treatment and evidence collection without parental/guardian involvement, and the scope of confidentiality that minors are afforded. If the adolescent victim is a minor under the jurisdictional laws, the laws of the jurisdiction governing issues such as consent to the exam, mandatory reporting, and confidentiality should be followed. Support the use of coordinated community responses to sexual violence, such as Sexual Ass ault Response Teams (SARTs) or Sexual Assault Response and Resource Teams (SARRTs) . Although 1 Carolyn Ham, Reducing Language Barriers to Combating Domestic Violence: The Requirements of Title VI , Battered Women™s Justice Project, October 2004, http://new.vawnet.org/summary.php?doc_id=1621&find_type=web_desc_GC . 2 Paragraph adapted in part from the Ohio Protocol for Sexual Assault Forensic and Medical Examination , 2004, p. 2. http://www.odh.ohio.gov/~/media/ODH/ASSETS/Files/hprr/sexual%20assult/adultprotocol2011.ashx .
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2 this document is directed primarily toward medical personnel and facilities, it also provides guidance to other key responders such as advocates and law enforcement representatives. This type of coordinated community response is supported by the Violence Against Women Act and subsequent legislation. Such a response can help afford victims access to comprehensive immediate care, minimize the trauma victims may experience, and encourage them to utilize community resources. It can also facilitate the criminal investigation and prosecution, increasing the likelihood of holding offenders accountable and preventing further sexual assaults. Address the needs of victims while promoting the criminal justice system response. Stabilizing, treating, providing social and legal services, including knowledge of immigration protections, and engaging victims as essential partners in the criminal investigation are central a spects of the protocol. Thus, this protocol includes information about concepts such as ﬁ anonymous reporting,ﬂ which may give victims needed time to decide if and when they are ready to engage in the criminal justice process. An anonymous report may also p rovide law enforcement agencies with potentially useful information about sex crime patterns in their jurisdictions. 3 The objective is to promote better and more victim -centered 4 evidence collection, in order to provide better assistance in court proceedin gs and hold more offenders accountable. Promote high -quality, sensitive, and supportive exams for all victims, regardless of jurisdiction and geographical location of service provision. The protocol offers recommendations to help standardize the quality of care for sexual assault victims throughout the country and is based on the latest scientific evidence . It also promotes timely evidence collection that is accurately and methodically gathered, so that high -quality evidence is available in court. This protocol discusses the roles of the following responders: health care providers, advocates, law enforcement representatives, forensic scientists, and prosecutors , as well as interpreters . Clearly, each of these professions has a distinct and complementary role in responding to sexual assault . But rather than dictate who is responsible for every component of the response or within the exam process, the protocol is designed to help communities consider what each procedure involves and any related issues. With this information, each community can make decisions for its jurisdiction about the specific tasks of each responder during the exam process and the coordination needed among responders. The following is a general description of the responsibilities with w hich each responder may assist :5 Advocates may be involved in initial victim contact (via 24 -hour hotline or face -to -face meetings); offer victims advocacy, support, crisis intervention, information, language assistance services , including interpreters, and referrals before, during, and after the exam process; and help ensure that victims have transportation to and from the exam site. They often provide comprehensive, longer term services designed to aid victims in addressing any needs related to the ass ault, including but not limited to counseling, legal (civil , criminal , and immigration ), and medical system advocacy . Law enforcement representatives (e.g., 911 dispatchers, patrol officers, officers who process crime scene evidence, detectives, and inve stigators) respond to initial complaints, work to enhance victims™ safety, arrange for victims™ transportation to and from the exam site as needed, interview victims in a language they understand , collect evidence from the scene, coordinate collection and delivery of evidence to designated labs or law enforcement facilities, interview suspects, and conduct other investigative activities (such as interviewing suspects and witnesses in a language they 3 States are responsible for ensuring that the costs associated with performing a medical forensic examination are paid and ens uring that all victims of sexual assault are provided the opportunity to have a medical forensic examination conducted, regardless of whether they choose to participate in the criminal justice system. 4 Please see the section on ﬁVictim -Centered Careﬂ beginning on page 29 for more explanation of this term. 5 There are instances where a case may be prosecuted con currently in two or more jurisdictions. For example, sexual assault cases occurring on Indian reservations can be prosecuted concurrently in tribal and state or federal court. In such situations, e ach sovereign will likely have its own victims™ advocate, l aw enforcement, prosecutor , and judicial/court officers. Coordination of services in multijurisdictional investigations and prosecutions is critical to the success of the criminal case and the well -being and healing of the victim.
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