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Evaluation and Management of the Sexually Assaulted or Sexually Abused patient

Evaluation and Management of the Sexually Assaulted or Sexually Abused patient

Product code :314500

The evaluation of the sexually assaulted or abused patient, particularly those with cognitive impairment or young age, is a challenge for health care professionals. Appropriate management of the patient requires a standardized clinical evaluation, an effective interface with law enforcement for the handling of forensic evidence, and coordination of the continuum of care with a community plan. The clinician must address the medical and emotional needs of the patient while addressing the forensic requirements of the criminal justice system. Medical issues include treatment of acute injuries and evaluation for potential sexually transmitted diseases and pregnancy. Emotional needs include acute crisis intervention and referral for appropriate follow-up counseling. Forensic tasks include thorough documentation of pertinent historical and physical findings, proper collection and handling of evidence, and presentation of findings and conclusions in court.

 

This handbook was first produced by the American College of Emergency Physicians in 1999. This project was an enormous undertaking at the time and was produced under its contract 98-0347(P) with the U.S. Department of Health and Human Services,  Health Resources and Services Administration, Maternal and Child Health Bureau. Several key stakeholder organizations were assembled to produce and review this handbook.

Since the first production of this handbook, “A National Protocol for Sexual Assault Medical Forensic Examinations” was developed by the US Department of Justice/Office for Violence Against Women. This was revised in 2013. In addition, ACEP created the Forensic Medicine Section in 2009. One of the goals of the section was to revise and update this handbook. In 2011, the Forensic Medicine Section was awarded an ACEP Section Grant to accomplish this goal.


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Ralph J. Riviello, MD, MS, FACEP

Heather V. Rozzi, MD, FACEP

Project Co-Directors

Table of Contents

Chapter 1. Sexual Assault and Society ............................................................. 15

Heather V. Rozzi, MD, FACEP Your State/Local Laws.............................................................................. 15 Societal Costs of Sexual Assault ...................................................................... 15 Coordinated Community Response Plan............................................................... 16 Sexual Assault Response/Resource Team (SART) Development .......................................... 17 Victim-Centered Responsibilities Matrix .............................................................. 19 Victim-Centered Responsibilities Matrix .............................................................. 20

Chapter 2. Sexual Assault Nurse Examiner (SANE) Development ................................. 21

Sheila Steer, MD and Valerie Prulhiere, RN Rape in the United States ........................................................................... 21 Demonstrating the Need for SANE Programs .......................................................... 22 History of SANE Program Development............................................................... 23

Chapter 3. Minimum Core Content ............................................................... 25

Wendy Wooley, DO

Chapter 4. Special Issues In Sexual Assault ....................................................... 27

Nicole K. Schaller, RN, BS, SANE-A, SANE-P and Derek J. Schaller, MD Acquaintance Rape................................................................................. 27 Special Populations (also see Module—Special Populations).............................................. 27 Drug-Facilitated Sexual Assault (DFSA)............................................................... 28

Chapter 5. Working with Law Enforcement ....................................................... 29

Nicole K. Schaller, RN, BS, SANE-A, SANE-P and Derek J. Schaller, MD

Physician’s Role.................................................................................... 29

Chapter 6. Privacy and Confidentiality ............................................................ 31

Ralph Riviello, MD, MS, FACEP HIPAA Exceptions ................................................................................. 31 Research and HIPAA............................................................................... 32 Privacy and Law Enforcement Officers................................................................ 32 Privacy and Photography............................................................................ 33 Confidentiality and ACEP ........................................................................... 33

Chapter 7. Injury in Sexual Assault ............................................................... 35

Monique Sellas, MD Physical Injury..................................................................................... 35 Genital Injury ..................................................................................... 35 Sexual Assault and Injury: Research Study Matrix...................................................... 37

Chapter 8. Documentation........................................................................ 39

Tiffany Bombard, BA, NREMTP and Shellie Asher, MD, MS Accounts of Victims or Witnesses..................................................................... 39 Past Medical History ............................................................................... 39 History of the Present Illness ........................................................................ 40 Physical Examination............................................................................... 41 Diagnostic Studies ................................................................................. 41 Assessment and Plan ............................................................................... 41

Chapter 9. Adult/Adolescent Patient Sexual Assault Examination................................. 43

Maura Dickinson, DO and Judith A. Linden, MD, FACEP Patient Notification................................................................................. 43 Patient Consent .................................................................................... 43 Distribution of Forensic Medicolegal Report........................................................... 44

Chapter 10. Adult/Adolescent Sexual Assault Forensic Medical Report............................ 45

Judith Linden, MD and Maura Dickinson, DO Patient Demographic Information.................................................................... 45 Law Enforcement Information....................................................................... 45 Patient History .................................................................................... 45 Assault History .................................................................................... 46 General Physical Examination and Findings ........................................................... 47 Genital Examination—Female ....................................................................... 48 Genital Examination—Male ......................................................................... 49 Document Specimens Submitted to the Forensic Laboratory............................................. 50 Personnel Involved in Sexual Assault Evaluation ....................................................... 50 Overall Clinical Assessment ......................................................................... 50 Law Enforcement Information....................................................................... 50 Patient Discharge .................................................................................. 50

Chapter 11. Male Patient Sexual Assault Examination ............................................. 51

Phillip Peterson, MD, and Ralph Riviello, MD, MS, FACEP Introduction....................................................................................... 51 Epidemiology...................................................................................... 51 History ........................................................................................... 52 Physical Examination and Injury Detection............................................................ 52 Disposition........................................................................................ 53

Chapter 12. Pediatric/Adolescent Patient Sexual Assault Examination ............................ 55

Dale P. Woolridge, MD, PhD Normal Physical or Congenital Findings that Can Be Confused with Child Sexual Abuse ..................... 55 Physical Findings in Child Sexual Abuse............................................................... 55 Conditions and Injuries that Can Be Confused with Child Sexual Abuse.................................... 56 Physical Examination Findings Consistent with Child Sexual Abuse ...................................... 56 Guidelines for Interviewing Children.................................................................. 57 Sexual Abuse Forensic Medical Report................................................................ 58 Developmental Staging ............................................................................. 64

Chapter 13. Special Examination Tools and Techniques ........................................... 67

Chamé Blackburn, MD and Lindsay Stokes, MD Colposcopy ........................................................................................ 67 Anoscopy ......................................................................................... 67 Foley Catheter Technique ........................................................................... 68 Toluidine Blue Staining............................................................................. 68 Alternate Light Source.............................................................................. 68

Chapter 14. Prophylaxis Care after Sexual Assault ................................................ 71

Sally Awad, MD Adult/Adolescents ................................................................................. 71 Children .......................................................................................... 72 Human Immunodeficiency Virus (HIV) ............................................................... 75 Emergency Contraception (EC) ...................................................................... 76

Chapter 15. Bite Mark Guidelines ................................................................. 79

Ralph Riviello, MD, MS, FACEP

Emergency Department Evaluation................................................................... 80

Chapter 16. Strangulation......................................................................... 83

William M. Green, MD, FACEP A Complexity of Challenges.......................................................................... 83 Basic Physiology ................................................................................... 83 Mechanisms and Definitions......................................................................... 84 Pathophysiology ................................................................................... 84 Clinical Symptoms ................................................................................. 85 Clinical Findings................................................................................... 86 Management and Documentation.................................................................... 87


Clinical Manifestations—CAUTION!.................................................................. 88 Evolving Clinical Approach .......................................................................... 88 Clinical Evaluation in the ED ........................................................................ 88 Documentation Chart for Attempted Strangulation Cases................................................ 89 Questions to ASK: Method and/or Manner ............................................................ 90

William M. Green, MD, FACEP Utility of Forensic Photography ...................................................................... 91 Utility of Forensic Images........................................................................... 91 Digital Forensic Photography........................................................................ 91 Forensic Imaging for Non-Professional Photographers.................................................. 91 Admissibility of Digital Photographs.................................................................. 92 Basic Forensic Photography: Principles and Techniques................................................. 93

Chapter 18. Quality Assurance for Sexual Assault Services ........................................ 95

William M. Green, MD, FACEP Improving Practice and Promoting Effective Community Partnerships .................................... 95 Quality Assurance: Basic Definition................................................................... 95 SAFE Team Quality Assurance....................................................................... 96 Peer Review....................................................................................... 97 SART Quality Assurance ............................................................................ 97 Patient Satisfaction Surveys ......................................................................... 98 Evaluation of Outcomes............................................................................. 98

Chapter 19. Forensic Laboratory Testing.......................................................... 99

Rebecca Hierholzer, MD, FACEP

General Rules for Forensic Evidence Collection (Module—Adult/Adolescent Patient)........................ 99 Evidence Collection Kits ............................................................................ 100 Use and Quality Control of Desiccant Packs1 ........................................................... 100

Chapter 20. Cultural and Linguistic Aspects of Sexual Assault Care ............................... 101

Michael L. Weaver, MD, FACEP

Chapter 21. Special Populations................................................................... 107

Heather V. Rozzi, MD, FACEP Elderly Victims .................................................................................... 107 Victims with Physical and Cognitive Disabilities........................................................ 107 Lesbian/Gay/Bisexual/Transgender Victims........................................................... 107 Prisoners ......................................................................................... 108 Intoxicated or Unconscious Patients.................................................................. 108

Chapter 23. Suspect Examination ................................................................. 109

Mary Carr, MD Payment .......................................................................................... 109 Documentation.................................................................................... 109 Evidence Kits ...................................................................................... 109 Facility ........................................................................................... 109 Consent........................................................................................... 109 Examination ...................................................................................... 110 Suggested Suspect Exam Protocol.................................................................... 111

Chapter 23. Testimony ............................................................................ 113

Tiffany Bombard, BA, NREMTP and Shellie Asher, MD, MS, Albany Medical College ............................ 113 Order of Events .................................................................................... 113 Preparation for Trial................................................................................ 114 Arriving in Court ................................................................................... 114 During the Trial.................................................................................... 115 Summary ......................................................................................... 116

Appendices....................................................................................... 117

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