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EVAWI > Resources > Best Practices > FAQs > Medical Forensic Exam
Q Should health care providers encourage victims to report to law enforcement?
Q How should Sexual Assault Forensic Examiners (SAFEs) conduct their interviews, to take into account the research on trauma and memories?
Q

If the SAFE provides information to a victim about the findings from a medical forensic exam, can this potentially compromise this case?

Q Should SAFEs have follow up contact with the victim?
Q How many sexual assault victims have a medical forensic exam?
A Should health care providers encourage victims to report to law enforcement?

This question is addressed on pages 51-52 of the National Protocol for Sexual Assault Medical Forensic Examinations (Adolescent/Adults):

Service providers should discuss all reporting options with victims and the pros and cons of each, including the fact that delayed reporting may be detrimental to the prosecution of an offender. Victims need to know that even if they are not ready to report at the time of the exam, the best way to preserve their option to report later is to have the exam performed. Information should be provided in a language victims understand.

Some victims, however, are unable to make a decision about whether they want to report or be involved in the criminal justice system in the immediate aftermath of an assault. Pressuring these victims to report may discourage their future involvement. Yet, they can benefit from support and advocacy, treatment, and information that focuses on their well-being.  Recognizing that traumatic injuries heal and evidence on their bodies is lost as time passes and that they may report at a later date, victims can also be encouraged to have the medical forensic exam conducted. Victims who are recipients of compassionate and appropriate care at the time of the exam are more likely to cooperate with law enforcement and prosecution in the future.  Except in situations covered by mandatory reporting laws, patients, not health care workers, make the decision to report a sexual assault to law enforcement (p. 51).

A How should Sexual Assault Forensic Examiners (SAFEs) conduct their interviews, to take into account the research on trauma and memories?

While it is important for health care providers who conduct medical forensic exams to keep in mind the negative effects of trauma on memory and recall, the implications are different than they are for law enforcement. Most importantly, it is clear that SAFEs (Sexual Assault Forensic Examiners) cannot postpone the exam because the health implications of delaying medical treatment can be devastating on the long term health of the patient. Additionally, evidence can degrade or be lost over time (e.g., biological evidence and visible evidence of injuries). The objectives of the exam dictate that it be conducted as soon as possible once the victim has initiated contact. This includes the history taken by the SAFE following recommendations in the National Protocol for Sexual Assault Medical Forensic Examinations(2004) published by the Office on Violence Against Women, U.S. Department of Justice.

The implications for SAFEs are thus twofold. First, SAFEs must keep in mind the negative effects of trauma on memory and recall, particularly when victims provide information that is disorganized, inconsistent, or even untrue. All too often, this is seen as cause for suspicion by law enforcement professionals, health care providers, and others – yet such behavior should be seen as the natural result of trauma and the intense pressures felt by victims in the immediate aftermath of a sexual assault.

Second, these issues highlight the importance of follow-up contact with patients whenever possible. This issue is discussed in greater detail elsewhere, but it is worth mentioning here as well because victims may recall additional information in the days, weeks, or even months after the sexual assault. If the SAFE is able to check in with the victim 24-48 hours after the exam, this allows the SAFE to check on the victim’s physical and emotional well-being, address any remaining medical concerns, and determine the victim’s level of compliance with the medications and medical treatment.

It must be emphasized that the purpose of this follow-up contact is not to assist with the investigation, although it is possible that some of the information provided by the victim may in fact be useful for law enforcement. For example, victims may call to let the SAFE know that their injuries are not healing as they should, or that they are having trouble sleeping or eating, etc. In response, the SAFE will be able to address these concerns as a health care professional, and the documentation of these concerns may also provide additional information that can be incorporated in the investigative file compiled by law enforcement.

Follow-up also establishes a line of communication that victims can access if they need to contact the SAFE at any point in the future. Unfortunately, many SAFEs do not have the resources or mechanisms in place to be able to provide routine follow-up with victims.

Note: Thanks to Kim Day, RN, FNE, SANE-A, SANE-P for her assistance with this response. She serves as the SAFE Technical Assistance Coordinator for the International Association of Forensic Nurses (IAFN).

A If the SAFE provides information to a victim about the findings from a medical forensic exam, can this potentially compromise this case?

No. Whether or not a fact is disclosed to a patient is completely up to the SAFE. If the SAFE feels that a particular fact is one that the patient should have, then the patient should have it. No law enforcement officer should ever seek to influence how a medical provider treats a patient. A medical forensic examination (including the evidence gathering process) is done for the patient's benefit, not for the benefit of law enforcement alone. Further, there is no known legal reason why revealing the existence of a piece of evidence (e.g., the presence of sperm) could compromise the case from a strict legal standpoint. Perhaps, in the mind of an investigating officer, it may not be seen as a good thing to reveal this fact because of its effect on the victim, but that is an issue that law enforcement investigators and prosecutors will have to deal with when the time comes. It is not the SAFE’s job to seek to conceal information from patients regarding their own examinations at anyone's behest.

A Should SAFEs have follow up contact with the victim?

Yes, if possible. This is the recommendation of the National Protocol for Sexual Assault Medical Forensic Examinations (2004) published by the Office on Violence Against Women, U.S. Department of Justice. The National Protocol recommends that SAFEs follow up with victims by phone within 24-48 hours of the exam, (if they consent). This follow-up contact allows the SAFE to check on the patient’s physical and emotional well-being, address any remaining medical concerns, and determine the patient’s level of compliance with the medications and medical treatment. The SAFE should therefore ask the patient for their consent to follow up and determine an optimal day, time, and location for this contact.

Follow-up examination of the patient can be particularly critical when genital trauma is identified during the exam. A follow-up appointment can be used to evaluate the physical well-being of the victim and, it can also be used to strengthen the documentation of evidence regarding genital and non-genital injuries sustained by the sexual assault victim.

  • Specifically, the American College of Emergency Physicians (ACEP) recommends that sexual assault victims be referred for follow-up examinations at 2 weeks, 3 months, and 6 months after the assault to evaluate for pregnancy and sexually transmitted diseases (American College of Emergency Physicians, 1999).
  • It also may be useful to document resolution of injury and in cases where there may be a question of whether an observation from the examination was related to injury or normal anatomical variants. Photodocumentation at the time of the follow-up may also be helpful for comparison purposes.
  • There are also situations where the SAFE is unsure whether the suspected injury is due to the victim’s medical history or other gynecological condition. In these cases, a follow-up examination can be used to evaluate whether the suspected injury appears the same at this later point, which would suggest that it was in fact due to a gynecological condition of some kind, or if it healed as an injury naturally would (thus suggesting that it was in fact an injury).

The National Protocol (2004) also encourages follow-up care to address any issues regarding the testing and treatment of sexually transmitted infections (STI’s) as well as HIV. Yet unfortunately, many SAFEs do not have any mechanism in place for routine follow-up contact with patients. This may be for a variety of reasons, including a lack of program funding for time or other limitations due to facilities or resources. For example, follow-up exams or contact with victims may not be reimbursable in every state. Therefore, this represents a best practice that communities can strive to implement.

Note: Thanks to Kim Day, RN, FNE, SANE-A, SANE-P for her assistance with this response. She serves as the SAFE Technical Assistance Coordinator for the International Association of Forensic Nurses (IAFN).

American College of Emergency Physicians (1999). Evaluation and management of the sexually assaulted or sexually abused patient. Manual prepared under contract 98-0347 (p) with the US Department of Health & Human Services.

A How many sexual assault victims have a medical forensic exam?

There are no exact figures for the number of sexual assault victims who obtain a medical forensic exam. There are only estimates for the number who seek medical care of any kind. Specifically, estimates range from 19-40% for the percentage of victims who seek medical care following their sexual assault (for review, see Campbell, 2008; also Kilpatrick et al., 2007; Zinzow et al., 2012).

Of those who report their sexual assault to law enforcement, approximately half (44-55%) have a medical forensic examination (McEwan, 2011; Peterson et al., 2010).

Campbell, R. (2008). The psychological impact of rape victims’ experiences with the legal, medical and mental health systems. American Psychologist, 63 (8), 702-717.

Kilpatrick, D.G., Resnick, H.S., Ruggiero, K.J., Conoscenti, M.A. & McCauley, J. (2007). Drug-Facilitated, Incapacitated, and Forcible Rape: A National Study. Washington DC: National Institute of Justice, Office of Justice Programs, U.S. Department of Justice (NCJ 219181).

Zinzow, H.M, Resnick, H.S., Barr, S.C., Danielson, C.K. & Kilpatrick, D.G. (2012). Receipt of post-rape medical care in a national sample of female victims. American Journal of Preventive Medicine, 42 (2), 183-187.

McEwan, T. (2011). The Role and Impact of Forensic Evidence in the Criminal Justice Process. Washington, DC: National Institute of Justice, Office of Justice Programs, U.S. Department of Justice (NCJ 236474).

Peterson, J., Sommers, I., Baskin, D. & Johnson, D. (2010). The Role and Impact of Forensic Evidence in the Criminal Justice Process. Washington, DC: National Institute of Justice, Office of Justice Programs, U.S. Department of Justice (NCJ 231977).

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