Adolescent Health Care: A Practical Guide

Chapter 81

Sexual Assault and Victimization

Vaughn I. Rickert

Owen Ryan

Mariam R. Chacko

Sexual Assault

Sexual assault and victimization among adolescents and young adults has been referred to as a hidden epidemic because of the high rates of occurrence and its infrequent disclosure (Rickert et al., 2004). In fact, female adolescents aged 16 to 19 years and young adults 20 to 24 years of age, are 4 times more likely to be sexually assaulted than women in all other age-groups (Golding et al., 1997). Since prevalence estimates of sexual victimization have been largely geared toward women and those in heterosexual relationships, prevalence of victimization among adolescents and young adults in same gender relationships is yet to be determined. Regardless, in most instances among adolescents and young adults, the perpetrator of sexual victimization is a date or an acquaintance rather than a stranger.

Sexual assault and victimization is one of the most devastating encounters a person can experience and can dramatically change the victim's view of self and the world. The victim is the object of a hostile, dehumanizing attack that can have long-lasting effects on concepts of self-worth and identity. This is particularly true for the adolescent who is learning to manage feelings of sexual arousal, developing new forms of intimacy and autonomy, experiencing intimate interpersonal relationships, and building skills to control the consequences of sexual behavior. Sexual victimization or attempted assault as a first or early sexual experience may cause confusion between intercourse and violence and can jeopardize the person's sexual health.

The disclosure of sexual assault and victimization requires prompt medical and psychological intervention, but is rarely forthcoming. When forensic evidence is required, as in the case of sexual assault, only those primary care providers who are willing to devote the time and support needed should examine the sexual assault victim. Equally as important is a clinician's familiarity with the proper protocol for intervention including clinical, legal, and psychosocial techniques.

Provider-initiated screening to detect sexual victimization represents an important public health strategy to overcome the difficulty that some victims face when disclosing these violent events (Irwin and Rickert, 2005). Currently, fewer than half of providers routinely screen their adult patients for intimate partner violence; the prevalence or acceptability of screening practices among adolescents and young adults is unknown.

The terms used to describe the range of victimizations included in sexual assault are sometimes used interchangeably and yet not often particularly clear. Some of these terms have legal ramifications and reporting requirements that greatly impact prevalence and incidence rates. Following is a list of terms and definitions that will help provide a solid understanding of terminology used in the rest of this chapter. If a work is cited that has used a different definition, that definition is provided.

Sexual assault: Any act, either physical or verbal, of a sexual nature committed against another person that is accompanied by actual or threatened physical force. Sexual assault is an umbrella term that contains several different aspects of sexual violence and victimization.

Rape: Rape is a legal term with a definition that varies widely from state to state. In general, this term implies unlawful nonconsensual sexual activity carried out forcibly or under threat of injury against the will of the victim. Nonconsensual sex can be divided into two categories—those perpetrated by a stranger and those perpetrated by an acquaintance.Stranger rape applies to the former whereas the term acquaintance rape refers to the latter. Date rape, nonconsensual sex that occurs between two people in a romantic relationship, is a subset of acquaintance rape.

Sexual abuse: Usually refers to the sexual victimization of a minor. In certain contexts, the term can include consensual sex between minors or a minor and an adult (statutory rape, see “Legal Issues” section). Occasionally, the terms incest and intrafamilial sex become confused with sexual abuse. We define incest as sexual intercourse between closely related persons while intrafamilial sex consists of intercourse in a caregiving situation—both are forms of abuse. Sexual abuse, as with rape, is also primarily a legal term.

Epidemiology of Sexual Assault

The Bureau of Justice Statistic's (BJS) 2004 National Crime Victimization Survey (NCVS) reports that although aggregate numbers for violent crime reached their lowest point since 1973, aggregate numbers for rape and sexual assault rose by 6%. To understand the trend more precisely, however, it is necessary to consider these crimes

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separately. When rape (defined as forced penetration perpetrated on either a man or a woman) is considered by itself, there is a decrease of 28% in reported cases since 2001. Alternately, the more expansive category of sexual assault has seen consistent increases during the same time—a trend masked by the overall drop in reported rape cases. The disparity in these two trends emphasizes the need to consider sexual assault more broadly. According to NCVS, of the 203,680 rape and sexual assault cases where a female was the victim, only 34% of perpetrators were identified as strangers. Amongst the 6,200 male rape and sexual assault victims, a stranger perpetrated 50% of the attacks. Therefore, in a large majority of sexual assault cases, the victim knew the perpetrator.

Several studies have highlighted a significant period of vulnerability for adolescent females. The vast majority of assaults occur between the ages of 12 and 24 years with the largest number occurring between the ages of 16 and 24 years. Reporting of rape and sexual assault has remained inconsistent since 1993 with a high of approximately 50% reported in 2002 and a low of 30% throughout the 1990s. Currently, the reporting rate rests between 35% and 40%. However, providers must understand that prevalence estimates, especially trend analyses, are not without problems. Depending on the survey, different definitions are employed. For example, the BJS surveys exclude rape and sexual assault that result in homicide and the FBI's Uniform Crime Reporting (UCR) Program identifies rape as “carnal knowledge of a female forcibly and against her will.” Additionally, surveys that rely on police reports are often skewed by socioeconomic status. Therefore, prevalence estimates must be cautiously compared. Stratification of sexual assault estimates by demographic characteristics can be difficult to generalize and inappropriately interpreted.

  1. Risk factors
  2. Females: Age 16 to 19 years and 20 to 24 years
  3. A history of abuse (sexual or other) as a child or adolescent
  4. For females with younger age at menarche, greater number of dating and/or sexual partners, and a sexually active peer group
  5. For males, homelessness and disability (physical, cognitive, psychiatric)
  6. Alcohol use by perpetrator or victim, especially in a dating situation
  7. Dating relationships that include verbal or physical abuse
  8. Incidence
  9. In the 2005 Centers for Disease Control and Prevention (CDC, 2006) National Health Risk Behavior Surveillance report on adolescents, 7.5% of youth, 10.8% of females, and 4.2% of males reported that they had been forced to have sexual intercourse.
  10. A recent study reported that 1 in 12 children and youth (82 per 1,000) aged 2 to 17 years had experienced one or more sexual victimization during their lifetime; 32 per 1,000 had experienced a sexual assault; and 22 per 1,000 had experienced a completed or attempted rape (Finkelhor et al., 2005).
  11. Adults are responsible for a few victimizations (15% of general sexual victimizations and 29% of sexual assault) confirming that a vast majority of victimizations are perpetrated by peer acquaintances (Finkelhor et al., 2005).
  12. A 2000 survey by the National Center for Juvenile Justice found that two thirds of sexual assault victimizations reported to the police involved juvenile victims.
  13. In the U.S. Department of Justice's (DOJ) “Full Report of the Prevalence, Incidence and Consequences of Violence Against Women,” 17.6% of surveyed women stated they had been the victim of a completed or attempted rape at some time in their lives. Of those with a history of rape, 21.6% were younger than 12 years when they were first raped, 32.4% were aged 12 to 17. Therefore 9% of women in the overall population reported being a victim of sexual assault before the age of 18 years.
  14. Adolescents ≤18 years who experience sexual victimization are twice as likely to experience a future assault during their college years.
  15. Approximately 60% of sexual assaults occur at home or at the home of an acquaintance.
  16. The incidence of reported rapes is higher during the summer months and on weekends, and approximately two thirds of sexual assaults occur between 6 p.m. and 6 a.m. Sexual assaults are least frequent in December (FBI, 1999). The National Center for Juvenile Justice study found that there was increased vulnerability for adolescents and young adults immediately after school (3 p.m.) and later at night (between 11 p.m. and midnight).
  17. Forceful verbal resistance, physical resistance, and fleeing were all associated with rape avoidance, whereas nonforceful verbal resistance and no resistance were associated with being raped. Injury rates were no higher in women who used forceful resistance.
  18. Use of date rape drugs such as gamma hydroxybutyrate (GHB) acid and flunitrazepam (Rohypnol) are of concern, but limited data are available as to the prevalence of their use. Unfortunately, testing for these agents is compromised by time and drug test facilities (Weir, 2001).
  19. Sequelae

Most of the sexual violence that clinicians will encounter when treating adolescents and young women is that which has been perpetrated by an acquaintance or, in fact, a date. As a result, spontaneous disclosure of the victimization is not likely—either because the young person does not perceive this as a sexual assault, they are embarrassed, or they believe it is their own fault. Clinicians need to be aware of the sequelae that result from sexual victimization of adolescents to more appropriately identify youth in need of services.

Some of the reactions of adolescent victims are similar to those of adults, but there are important differences stemming from the developmental tasks facing adolescents. The major developmental tasks of adolescents include individuation and emancipation, intimacy, identity formation, and mastery, all of which may be affected by the experience of sexual victimization. Such an event often disrupts the adolescent's sense of equilibrium and growing identity. The assault itself and the reactions of family members may inhibit the growing need for independence and autonomy. Adolescent victims must deal with the realization that the events may not be under their control, a fact that may delay successful emancipation. Identity formation issues often cause adolescent victims to question their sense of self and sexuality. In

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the aftermath, an adolescent may act in an unexpected bizarre or inappropriate manner; for example, he or she may be aggressive or withdrawn, resent peer and parental attention, or act as if nothing happened.

Much of the specialized research in the study of sexual assault has focused solely on stranger rape, and, while these are important findings, they do not address the vast majority of sexual victimizations that occur in this population. The information provided in the following text has been broadened to include findings from research aimed to identify sequelae of sexual violence in general.

Adolescents who have been victimized experience significantly higher levels of depression and anxiety. Male and female high school–aged victims report decreased life satisfaction coupled with suicidal ideation and attempts. An adolescent's sexual health is greatly impacted by victimization. Typically, sexually victimized youth engage in higher risk sexual behaviors, have poorer attitudes and beliefs regarding sex, and demonstrate a greater prevalence of consequences from sexual activity, that is, unintended pregnancies and sexually transmitted diseases (STDs).

Several common responses to victimization among adolescents include the following:

  1. Phobias
  2. Somatic reactions
  3. Self-blame
  4. Loss of appetite
  5. Sleep disturbance
  6. Somatic responses

Sequelae particular to date rape may include self-blame, decreased self-esteem, and a difficult time maintaining relationships. Somatic responses can manifest as chronic pelvic pain or recurrent abdominal pain. In the most general case, the first 2 months postvictimization is a time of particular vulnerability for severe depression. Signs of post-traumatic stress disorder are not uncommon within the first year (Rickert et al., 2003).

Data suggest a link between sexual victimization, alcohol, and illicit drug use. These adolescents or young adults can be 2 or even 3 times as likely to begin using illicit drugs, smoke, or regularly consume alcohol as compared to their nonvictimized peers (Diaz et al., 2002).

Sexual Abuse

  1. Incidence

In 2005, the National Child Abuse and Neglect Data System (NCANDS) published the findings of its 2003 survey. Their data is derived from substantiated claims of abuse filed by state child welfare agencies. In 2003, sexual abuse accounted for 10% of all victimizations of children, totaling 45,634 cases—4 of which resulted in the death of the child. Unlike other types of child victimization that have seen recent declines, child sexual abuse has remained constant at 1.2 children per every 1,000. The most recent National Incidence Survey (NIS) found that girls were 3 times as likely as boys to be sexually abused, and that vulnerability to sexual abuse remained consistent after age 3.

The NCANDS statistics confirm that adolescents and young adults are most vulnerable to sexual abuse at the hands of those closest to them. Sixty-nine percent of perpetrators were a parent, a relative, or a partner to the parent—the largest percentages falling in the first two categories. It has also been shown that sexual abuse cases are less likely to receive services from child welfare agencies than any other type of abuse. Reasons for this disparity were not explored.

Only 8.5% of sexual abuse case reporting came from medical professionals, just slightly higher than the 7.9% reported by parents. This figure underscores the acute need for trained medical professionals who feel comfortable and are skilled at screening for victimization.

  1. Situations that should alert the provider to suspect abuse:
  2. STD infection (including gonorrhea, syphilis, herpes, Trichomonasinfection, and condylomata) in a prepubertal adolescent or any adolescent with no history of sexual intercourse.
  3. Recurrent somatic complaints, particularly involving the gastrointestinal, genitourinary, or pelvic areas.
  4. Behavioral indicators include:
  • Significant change in mood, onset of withdrawal from usual family, school, and social activities
  • Patterns of disordered eating
  • Running away from home
  • Suicidal and self-injurious gestures
  • Rapid escalation of alcohol and/or drug abuse
  • Onset of promiscuous sexual activity
  • Early adolescent pregnancy
  • Onset of sexual activity before age 13 years
  • Sexualized play in the prepubescent child
  1. Sequelae

The occurrence of sexual abuse during childhood has been linked to a variety of psychological and emotional problems during adolescence, with some continuing into adulthood. The relationship between severity of abuse, frequency of abuse, and subsequent mental health disorders remains elusive. Some data suggest a strong and positive relationship between severity of abuse and subsequent symptom expression, while other studies do not. Regardless, sequelae include depression, suicidal ideation and attempts, substance abuse, post-traumatic stress disorder, eating disorders, and precocious sexual behaviors (e.g., earlier age at first coitus and greater number of lifetime partners). In addition, childhood sexual abuse for females has been linked to acquaintance and date rape as an adolescent or young adult. Therefore, victims of child sexual abuse are likely to present with a number of immediate psychological and emotional sequelae and have subsequent symptoms during the recovery process.

Underserved Populations

Male Adolescents

Male adolescents who have been sexually abused are often overlooked and underserved. Most studies of victimization are weighted toward younger children or females. However, male sexual abuse is not uncommon and is significantly underreported. Since most perpetrators of sexual violence against adolescent males are male themselves, these victims may remain silent due to the homosexual aspect of

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an assault. In addition, practitioners may fail to recognize and pursue this possibility because of their lack of awareness of this problem.

Gay, Lesbian, and Bisexual

A small amount of research has been conducted on violence in same sex relationships. Of these, there is an even smaller amount that is applicable or can be generalized toward gay and lesbian adolescents (or those with same gender sexual partners). Critics maintain that studies of gay and lesbian populations either tend not to use standardized measures or provide obscure data regarding victim/perpetrator relationship.

A recent study attempted to map out victimization of gay, lesbian, and bisexual men and women across their lifetime (Balsam et al., 2005). The results identified a dramatically increased risk of child sexual abuse and adolescent victimization amongst gay, lesbian, and bisexual persons. Over the lifetime, gay and bisexual men were 5 times more likely to be sexually assaulted than heterosexual men; lesbian and bisexual women were twice as likely as heterosexual women.

As a comparison group, the researchers used heterosexual siblings of the sexual minority participants. They were able to identify that even within family groups, sexual orientation was a significant predictor of sexual victimization either by persons within the family or outside of it.

Research such as this can easily become tied up in misdirected debates of causality (e.g., did the childhood victimization result in homosexuality or bisexuality?) and thereby make claims of particular vulnerability difficult. With little doubt, although, it can be asserted that there is a great disparity in regard to sexual victimization between sexual orientations.

Transgendered Adolescents

There is limited research identifying the particular vulnerabilities of transgendered adolescents and young adults in regard to sexual victimization. This is an area of acute concern considering the data showing increased sexual health risks amongst transgendered men and women.

Developmentally Delayed Children

The NCANDS (2005) found that children with disabilities accounted for 6.5% of all victims. Disabilities included mental retardation, emotional disturbance, visual impairment, learning disability, physical disability, behavioral problems, or another medical problem. It is important for the clinician to remember that these data reflect substantiated cases of abuse; children with such conditions are undercounted as not every child receives a clinical diagnostic assessment by child protective service. Specific data for teens with disabilities are not available.

Earlier studies conducted among developmentally delayed populations suggest that most victims were women (72%). However, these studies included developmentally delayed individuals who had little difficulty with verbal communication. As expected, most of the perpetrators were men (88%) and included other individuals with mental retardation, paid staff, family members, and others. Most sexual abuse occurred in the victim's residence, and in 92% of cases the victim knew the abuser (Furey, 1994).

Homeless/Street Youth

Studies have found that homeless and street youth are particularly vulnerable to victimization and violence. One study noted that 85% of surveyed homeless youth had experienced violence, 34% of whom were sexually assaulted. The numbers highlight that not only are homeless youth more prone to sexual violence but youth who have been sexually victimized are prone to homelessness as well—15% of youth living on the street were victimized before their homelessness (Kipke et al., 1997).

Disclosure and Reporting

Screening

Disclosure of sexual assault as well as sexual victimization is rarely spontaneous and often deeply impacted by the adolescent's or young adult's beliefs surrounding their own victimization. Such sensitive information is more often revealed weeks or months after the assault rather than within a timeline in which emergency room care could be beneficial (Rickert et al., 2004). This lapse leaves primary care providers with an obligation to inquire about past and present sexual victimization in as sensitive a manner as possible.

  1. Screening measures: There are currently several useful screening measures that can be easily employed by a clinician and take <15 minutes.
  2. Home, Education, Activities Drugs, Depression, Suicidal ideation, Sex, Safety (HEADSSS) inventory: As listed in Chapter 3, the HEADSSS inventory is a helpful device to collect important psychosocial information.
  3. Other screening tools for adolescents and young adults include:
  4. Conflict in Adolescent Relationship Inventory (Wolfe et al., 2001)
  5. Sexual Experience Survey (Koss and Oros, 1982)
  6. Date and Family Violence and Abuse Scale (Symons et al., 1994)
  7. Sexual Aggression Questionnaire (Muehlenhard and Linton, 1987)

In addition, information pamphlets designed to help patients self-screen for dating violence or to increase awareness of sexual health issues can also be helpful. Some clinicians also find anticipatory guidance, a conversation centering on sexual health risk factors and warning signs for violence in partners, more helpful in completely serving the adolescent's needs.

  1. Screening process: Regardless of what sources are used, screening is a very delicate process. It is as important to elicit information of possible victimization as it is to create a supportive environment for the adolescent patient.
  2. Barriers: The main barriers for not disclosing information are mistrust of adults and professionals, a fear of the consequences of disclosure for their family and offender, and ignorance of the existence of protective agencies.
  3. Environments:}?> Environments that allow adolescents to talk and have their concerns valued, can do much to overcome these obstacles.

Within the patient/clinician conversation, adolescents should be provided accurate information about the help

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they can receive from their social network, protective agencies, rape crisis centers, and hotlines. It is recommended that the screening take place in a private, quiet space where only the provider and the adolescent or young adult are present. An example of an icebreaker that prepares the patient for some of the questions they will be asked is,

Because I want to help my patients, I ask everyone about topics that may be very sensitive or may make you uncomfortable. Sadly, some young adults come to my office having been hurt by people around them. It is important that I know those things to be able to help them out.

The concept of limited confidentiality should be introduced to the patient in a manner that conveys the legal obligations of the clinician, should any disclosure occur. Some providers choose to use a direct but nonthreatening statement similar to,

Generally, what you say in here stays in here, but there are some exceptions. If I feel that you may hurt yourself or someone else, or that you have been abused by someone, I will need to talk to others to help make sure you get all the care you need.

Consistently asking patients about sexual history, even if negative answers were received in prior instances, can allow for this part of the examination to become more routine.

  1. Sexual history:}?> Once these preliminary steps have been taken, a provider can begin to collect a sexual history that includes sexual partners and experience, any unwanted touch, or previous victimization. The incidence rate amongst young women makes this step in their care especially necessary.
  2. Examination:}?> If the patient discloses that injuries were sustained, a thorough examination, consented to by the patient and described in detail in the section “Physical Examination”, will be required. This consent must not be general. The adolescent will need to know and consent to the specific purpose and procedures involved in the examination, including the stages of a rape kit.

It should be noted that for those adolescents who have experienced a recent victimization or are seeking treatment because of assault, it may be important to have a family member or friend present for the examination. Additionally, the provider can help the victim regain a sense of control over his or her body by encouraging them to make as many decisions during their examination as possible. It is crucial that the victim be informed that he or she is in control of what will be done and that, at any point, they can refuse examination, treatment, or stop the examination. For further clinical interventions in sexual violence refer to the section “General Forensic Background”.

Reporting

The following professional guidelines have been endorsed by several prominent organizations regarding the screening and reporting of sexual victimization among adolescents and young adults (Society for Adolescent Medicine, 2004).

  1. Sexual activity and sexual abuse are not synonymous. It should not be assumed that adolescents who are sexually active are, by definition, being abused. Many adolescents have consensual sexual relationships.
  2. It is critical that adolescents who are sexually active received appropriate confidential health care and counseling.
  3. Open and confidential communication between the health professional and the adolescent patient, together with careful clinical assessment, can identify most sexual abuse cases.
  4. Physicians and other health professionals must know their state laws and report cases of sexual abuse to the proper authority, in accordance with those laws, after discussion with the adolescent and parent as appropriate.
  5. Federal and state laws should support physicians and other health care professionals and their role in providing confidential health care to their adolescent patients.
  6. Federal and state laws should affirm the authority of physicians and other health care professionals to exercise appropriate clinical judgment in reporting cases of sexual activity.

Their position stresses the power of health care workers involved in primary care to clinically assess for sexual abuse or victimization. It equally emphasizes how state and federal laws that require health care providers to report particular sexual activity to adults responsible for the child's care impede this power.

Legal Issues Related to Reporting of Sexual Assault and Victimization

All 50 states require reporting of sexual abuse (also referred to as sexual assault) of minors; but there are a variety of ways in which states approach these issues under their mandatory child abuse reporting laws. Many states laws include a definition of sexual abuse, sexual intercourse, and other sexual acts that involve minors under a specific age (Society for Adolescent Medicine, 2004). Some states include only abuse that is perpetrated by parents, guardians, custodians, or caretakers, while others include acts of unrelated third parties. There are also state statutes for the screening and reporting of domestic violence, partner abuse, and violent injuries that may apply to adolescents and young adults. The child abuse and other reporting laws however, do not always encompass all aspects of assault and victimization and therefore some issues, such as victimization that occurs between adolescent and young adult dating partners, may fall outside the purview of mandatory reporting.

Every state has mandatory reporting of a reasonable suspicion of child abuse, including sexual abuse, to a designated authority. Mandated reporters of child abuse include virtually all medical and health professionals involved in the care of adolescents. The abuse does not need to be proved before being reported. An area of concern is that confidentiality is broken when abuse is reported, whether the teen or family does or does not want the incident reported. Society has determined that the public's right to protect a victim of child abuse supersedes

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a patient's right of privacy. This leads to more reporting of suspected abuse, but less protection of physician–patient confidentiality. In the role of mandated reporters, health care professionals are generally afforded legal immunity for making reports of suspected abuse. Failure to report can result in civil liability or criminal penalties.

In recent years, there has been an increased effort at the federal level and in many states to increase the reporting by health care providers of sexual activity involving minors under child abuse reporting laws. In addition, an area of potential confusion and controversy is the reporting of “statutory rape.” Although this term does not appear in most states' laws, it is generally used to refer to sexual intercourse that is illegal even if it is consensual; and can refer either to sexual contact between two minors or between a minor and an adult. Policy makers at the federal and state levels have attempted to increase the enforcement of statutory rape laws, partially in response to suggested links between teenage pregnancy and “statutory rape.”

Many states have attempted to increase the reporting of sexually active minors under child abuse reporting laws, either through legislative and policy changes or enforcement of existing laws. These efforts have focused particular attention on younger adolescents who are sexually active. An area of particular confusion and controversy is the reporting of statutory rape—defined as consenting sexual contact between two minors or one minor and an adult. At least one state has attached legislative riders to state appropriations measures for programs that provide family planning services, imposing specific conditions on service contracts for these programs (Title V, X, XX, and Medicaid). In that state, according to health department regulations, these funds will only be distributed to recipients who show good faith efforts to comply with all child abuse reporting guidelines and requirements. Health departments conduct random monitoring of records of minors on an annual basis. The impact of implementing these measures is yet unknown. However, based on experience, many providers sense that law enforcement officials do not process most of these reports.

In summary, there are a variety of considerations that can have a bearing on when sexual activity, especially in a young adolescent, must be reported. These include use of coercion or pressure, force or the threat of force, or a wide age difference between partners even if the adolescent and parent(s) consider the current relationship consensual and nonabusive. Owing to the variations in reporting laws among states, it is essential that health care providers consult their local legal and medical authorities regarding laws for their state and be aware of their institution policies as it relates to the screening and reporting of child abuse, sexual abuse, sexual victimization, and violence.

Evaluation of Sexual Abuse and Assault in Adolescents: Medical and Forensic Aspects

Medical Evaluation

The following pages are meant as a guide for clinicians performing medical examinations on sexually victimized adolescents and young adults. It is important to understand that a large majority of these individuals will present with conditions that do not lend themselves to examination. Victimizations of coercion or date rape can often involve “forced consent,” leaving the victim with more palpable psychological scars than physical.

Owing to the burden of incidence on young women, the information provided is skewed toward the perspective of a female victim. Following the information on forensic examination and treatment, there is a special note on STD prevalence in sexual victimization and a smaller piece on the legal processes involved in prosecution.

General Forensic Background

Facilitating an Appropriate Medical Examination

Medical and mental health providers who suspect that their patient has experienced sexual victimization during the course of their clinical practice need to facilitate an appropriate medical examination based on established procedures. Clearly, the earlier an examination is performed the more likely the evidence of trauma will be noted. Because this is an extremely vulnerable situation for the victim, only practitioners with the time, sensitivity, and training required to conduct a full examination should do so.

Physicians and nurses have an obligation to provide care to victims, which involves being both a “medical detective” (being able to provide a legal defense in all cases including those in which a rape kit may or may not have been done) and a supportive care provider. Therefore, these individuals must be trained and comfortable in examining the sexually abused or assaulted adolescent. The training includes the ability to complete a rape kit, and to have knowledge of internal and external genital and anal anatomy in females and males. It also includes the ability to be vigilant in the documentation of a detailed history of acute and chronic traumatic injuries. To the experienced examiner, what might otherwise seem like subtle findings can actually be determinants of previous trauma to the genital area.

Facilitating Appropriate Forensic Procedures

The rape kit enables collection of evidence such as semen, clothing, and debris for forensic examination. In some jurisdictions, the cutoff period for collecting evidence for the rape kit has been extended beyond the standard 72 hours of a sexual abuse or assault incident, since sperm has been identified in the cervix up to a week later even after showering and bathing. In addition, the availability of deoxyribonucleic acid (DNA) amplification technology now used to identify assailants more accurately allows for collecting evidence beyond the 72-hour period (American Academy of Pediatrics, 2001; U.S. Department of Justice, Office on Violence Against Women, 2004). Individual jurisdictions determine the maximum time interval (36 hours to 1 week) in which evidence may be collected. Changing clothes, showering, brushing teeth can also change the yield of the forensic examination.

In the event that the adolescent declines a forensic examination, a speculum examination should not be undertaken to obtain STD tests until after 96 hours. This allows the victim the time to change her mind and permit a forensic examination within the designated time. A speculum examination conducted before forensic work will call into question the accuracy of evidence that may later be collected.

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Magnification Aids and Photography

Magnification aids and photography are not absolutely necessary but can be useful in the evaluation and documentation of genital trauma. Photographs can provide an accurate record of significant genital injuries and fresh trauma (bloody tears and complete clefts). They can also be available at a later date for a second opinion. However, photographs and magnification may not be as helpful in documenting subtle findings such as erythema, swelling, or small labial tears. Providers have typically used the colposcope because it has excellent magnification, light, and a built-in 35-mm camera with approximately 12 in. between the examiner and the body. An alternative to the colposcope is the medscope, an adapted dental camera that takes digital prints. It has greater depth of field, can be used to document injuries elsewhere on the body, and is easy to operate, portable, and less cumbersome than the colposcope. Images are taken using the foot, freeing the hands to conduct the examination and reducing the risk of contaminating the evidence. Since the medscope does not have definite magnification ranges like the colposcope, the digital prints cannot be enlarged or reprinted like 35-mm prints (U.S. Department of Justice, Office of Justice Programs, Office for Victims of Crime Bulletin, 2001).

A clear protocol for the secure filing of print and digital photographs for forensic evidence will reassure a fearful adolescent about the security of the photographs.

TABLE 81.1
Findings Diagnostic of Trauma and/or Sexual Contact
a

HIV, human immunodeficiency virus.
aFindings which in the absence of a clear, timely, plausible history of accidental injury or nonsexual transmission should be reported to child protective services.
Adapted from Adam J, Medical evaluation of suspected sexual abuse. J Pediatr Adolesc Gynecol 2004;17:191 (with permission).

1.  Moderate specificity for abuse

1.  Acute lacerations or extensive bruising of labia, perihymenal tissues, penis, scrotum, or perineum (may be from unwitnessed accidental trauma).

2.  Scar of posterior fourchette (discrete, pale, off the midline). Scars are very difficult to assess unless acute injury at same location was documented.

3.  Fresh laceration of the posterior fourchette, not involving the hymen (must be differentiated from dehisced labial adhesion or failure of midline fusion, or may be caused by accidental injury).

4.  Perianal scar. Discrete, pale, off the midline (rare, difficult to assess unless acute injury at the same location was previously documented; may be due to other medical conditions such as Crohn disease, or previous medical procedures).

2.  High specificity for abuse (diagnostic of blunt force penetrating trauma)

1.  Laceration (tear, partial or complete) of the hymen, acute.

2.  Ecchymosis (bruising) on the hymen.

3.  Perianal lacerations extending deep to the external anal sphincter (not to be confused with partial failure of midline fusion).

4.  Hymenal transection (healed). An area where the hymen has been torn through, to or nearly to the base, so there appears to be virtually no hymenal tissue remaining at that location, confirmed using additional examination techniques such as a swab, prone knee-chest position, Foley catheter, water to float the edge of the hymen. This finding has also been referred to as acomplete cleft in sexually active adolescents and young women.

3.  Presence of infection confirms mucosal contact with infected genital secretions; contact most likely to have been sexual in nature

1.  Positive confirmed culture for gonorrhea, from genital area, anus, and throat, in a child outside the neonatal period.

2.  Confirmed diagnosis of syphilis, if perinatal transmission is ruled out.

3.  Trichomonas vaginalis infection in a child older than 1 year, with organisms identified (by an experienced technician or clinician) in vaginal secretions by wet mount examination or by culture.

4.  Positive culture from genital or anal tissues for Chlamydia. If child is older than 3 years at time of diagnosis, and specimen was tested using cell culture or comparable method approved by the Centers for Disease Control and Prevention. Positive serology for HIV, if neonatal transmission and transmission from blood products has been ruled out.

4.  Diagnostic of sexual contact

1.  Pregnancy.

2.  Sperm identified in specimens taken directly from a child's body.

Interpretation of Findings

A classification system has been developed by Adams (2004) to assist clinicians in the interpretation of physical

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and laboratory findings and to provide an opinion as to the likelihood of sexual abuse or assault in children and adolescents (Table 81.1).

Conducting the Medical History

  • If a rape kit is being completed, consent needs to be obtained from the adolescent for the forensic examination, treatment, collection of evidence, and release of medical records.
  • A brief description of the incident including body parts touched, orifices penetrated, the geographic location of the assault, identity of the assailant or alleged perpetrator (if known), whether a condom was used, whether any bleeding was noted from contact sites at the time of the abuse or assault, and method by which the assailant left the scene.
  • Whether a weapon was used and any injuries sustained at the time of attack.
  • Whether any illicit drugs or alcohol were used to render the victim helpless.
  • Date of last menses and use of sanitary pads and/or tampons.
  • Date and time of last voluntary coitus, other recent sexual experiences.
  • History of previous STDs.
  • History of prior pregnancy.
  • Use of contraception.
  • Any significant actions after alleged assault, such as showering or douching, rinsing of mouth, and brushing of teeth.

Physical Examination

  • Before examining the patient, the medical provider should provide a step-by-step explanation of what he or she will be doing and why.
  • Reassure the patient that he or she will be in control.
  • Keep personal contact with the patient, both through verbal and eye contact.
  • Proceed slowly, allowing the patient to relax.
  • During the examination, comment on unremarkable or normal findings. Frequently, the patient feels abnormal as a result of the attack and wonders whether his or her body is still the same. It is crucial to convey a sense of normalcy where appropriate. When physical findings are remarkable and injury is present, the medical provider should stress that these injuries are not the patient's fault.
  • The examination must include a thorough physical examination for bruises and healing abrasions followed by a genital examination for evidence of trauma and collection of specimens for STD.

General Physical Findings

  • General appearance, emotional state, and behavior should be recorded.
  • Condition of patient's clothing should be observed and documented.
  • All areas of the body should be explored for signs of trauma. Look closely at the neck and upper arms, where bruises resulting from forced restraint are apt to appear.
  • Examine the throat.
  • Check for abdominal crepitus; this may signify vaginal or rectal laceration with intra-abdominal bleeding.

Gender-Specific Considerations

Females

  • The proportion of adolescent females with genital injuries from nonconsensual intercourse is significantly higher than those from consensual intercourse (Adams, 2004).
  • Straddle injuries or injuries from sharp objects to the genital area are extremely rare.
  • Complete hymenal clefts are not commonly associated with tampon use but may occur during painful insertion (Emans et al., 1994). It would seem prudent for physicians to interpret such data in the court in the context of a specific case with adequate and detailed history (Goodyear-Smith, 1998).
  • Estrogen affects the adolescent hymen by making it elastic and thereby permitting penile penetration without tearing. Therefore, while posterior hymenal notches or clefts strongly suggest trauma to the area, absence of hymenal notches or clefts should not exclude the possibility of vaginal penetration.
  • Even when penile–vaginal penetration is certain, definitive findings may not be present (Kellogg, 2004).

Males

  • Evidence of trauma has been found in only approximately 20% to 37% of adolescent male sexual abuse or assault victims.
  • Most genital injuries from sexual abuse and assault involve the rectum and the penis. The perineum, scrotum, or testes follow far behind (Doan, 1983).
  • Rectal lacerations from sexual abuse or assault tend to be located at the 1, 5, 7, and 11 o'clock positions (Kadish et al., 1998).

Genital, Pelvic, and Rectal Examination

  • Position: An examination on an adolescent female is performed in the lithotomy position. Young and petite adolescent females and males can be examined in the knee-chest position for easier visualization of the anogenital area. The anal area in the larger and older male adolescent should be visualized with the adolescent lying in the lateral position and with one or both knees flexed.
  • External genitalia: Note and record signs of blood secretions and sites of bruising, hematoma, ecchymoses, abrasions, lacerations and redness, and swelling in the external genitalia, including the hymen. Application of toluidine blue will make local injuries in the female (the fossa navicularis, posterior fourchette, and hymenal membrane) more apparent.
  • Hymen: The hymen can be observed by using a cotton applicator swab moistened with water. Gently stretch the hymen all around to clearly define any partial or complete fresh hymenal tears, and the amount of hymenal tissue present, especially at the 6 o'clock position of the posterior rim where acute hymenal tears are more likely to be found (Slaughter 1997). Spread apart any areas that appear to be notches or clefts with the swab to define the depth of the notch or cleft. An alternative method to detect hymenal damage is by using a Foley catheter balloon technique. The provider inserts the balloon in the distal vaginal vault and expands the estrogenized hymen to full capacity so that injuries along the edge of the hymen can be visualized. This technique also allows for improved photodocumentation (Jones et al., 2003;

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Danielson and Holmes, 2004). Remember that the absence of notches does not rule out previous penetration; therefore, the term “intact” hymen should be avoided.

  • Anus: When anal penetration is reported in females or males, the perianal and anal area needs to be inspected carefully for scars, fissures, sphincter tears, evidence of chronic fissuring, distortion of the anus, skin tags, and localized venous engorgement. Recurrent anal penetration must be suspected when the skin around the anal opening is smooth and thickened and the external sphincter has lost its tone and it does not contract readily. Loss of tone is assessed by presence of a relaxed external anal sphincter almost to the point of gaping, along with loss of puckering of the mucous membrane. Location of anal findings using the face of a clock must be documented.
  • Internal examination: An internal pelvic and rectal examination must be performed if there is pain, bleeding, a history of vaginal or rectal penetration, or signs of injury. This should be performed after a thorough examination of the entire body. A primary responsibility of the physician is to avoid further trauma to the patient in performing this part of the examination. A warm water-lubricated speculum should be used for the vaginal examination. In the young peripubertal adolescent, a small-sized metal speculum is preferred for easier insertion and visualization. General anesthesia may be indicated. Injuries such as ecchymoses and tears to the vagina and cervix must be noted. An anoscopy or a proctoscopy is recommended when internal trauma and pathology (warts) is suspected. Internal trauma should be suspected when rectal bleeding, fever, or signs of an acute abdomen are present.

Collection of Specimens

  • Treatment for any and all significant trauma, including soft tissue injury as well as injury to the genital area should precede collection of medicolegal information.
  • When the kit is opened, the examiner should familiarize himself/herself with the contents of the rape kit and all hospital laboratory tests should be set up on the counter.
  • The provider first sees an instruction sheet, a consent form, and numerous sexual assault forensic examination forms. The sexual assault forensic examination forms include history, physical and genital examination records, a checklist of evidence items, follow-up plans, body diagrams for documentation of injuries, and police department documents (receipt of information and authorization for examination and payment). Finally, the rape kit also contains a paper sheet, envelopes, slides, and swabs.
  • Collection of legally mandated tests for the rape kit has to be synchronized with the general physical examination, pelvic examination, and hospital laboratory tests. For example, all tests for the rape kit or the hospital laboratory that are needed from the genital area should be obtained during the pelvic examination and blood tests for the rape kit and the hospital laboratory should be done upon completion of the examination. Remember patient permission is required for photographs of areas of trauma.
  • Legally mandated tests for evidence collection may include foreign hair collection, clothing, blood from victim for typing, filter paper disk with saliva from victim, and swabs from perianal, anal verge, and rectal canal for presence of acid phosphatase. Appropriate specimens for DNA testing should be obtained. The “chain of evidence” must be maintained when collecting forensic specimens by strictly following rape kit protocols or evidence will not be of value in criminal prosecution.
  • The Wood's lamp has been shown to be unreliable in screening for the presence of semen, but may be helpful in identifying foreign debris (Santucci et al., 1999).
  • Evidence for the kit is collected and handed over to a police officer according to legal procedure with associated specimen analysis cost covered by the police.

Hospital Laboratory Tests

  • Cultures: Gonorrheacultures should be obtained from the endocervix, rectum, and pharynx. Chlamydia cultures should be obtained from the endocervix and rectum. Noncultural techniques (i.e., U.S. Food and Drug Administration [FDA]-approved nucleic acid amplification tests) should not be used because they have inadequate specificity for criminal prosecution (Centers for Disease Control and Prevention, 2002).
  • Gram stain of any urethral or anal discharge should be obtained. A Gram stain from the cervix or vagina is not useful.
  • If genital ulcers or vesicles suspicious for herpes genitalisare present, a viral culture from the lesions should be sent for herpes simplex virus.
  • Wet mount of vaginal secretions should be prepared and examined for evidence of Trichomonasand bacterial vaginosis. If sperm are identified, the laboratory technician validates these findings with the examiner and/or a senior pathologist.
  • Serum sample for reactive protein reagin (RPR) or Venereal Disease Research Laboratory (VDRL) test should be obtained as a baseline test and repeated within 6 to 8 weeks for syphilis.
  • Serum sample for hepatitis B surface antigen and antibody should be obtained.
  • Discuss possible testing for human immunodeficiency virus (HIV) and provide appropriate pretest counseling. If testing is desired, a serum sample should be obtained and repeated at 6 weeks, 3 months, and 6 months.

Treatment

  • Patient instructions for managing any injuries, including those to the genital area should be provided, that is, cleaning area with an antibacterial agent, application of local antibiotic ointment, and sitz baths.
  • Clinicians need to be sensitive to the likelihood of gastrointestinal side effects from multiple oral medications dispensed or prescribed following a sexual assault evaluation. In this event, treatment should begin with emergency contraception and intramuscular medication for gonorrhea. Medications for other common STDs can begin after the emergency contraception regimen is completed.
  • Tetanus toxoid 0.5 mL intramuscularly (plus tetanus immune globulin if dirty wound) is indicated for severe or penetrating trauma.

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  • STD prophylaxis: Many specialists recommend routine preventive therapy after a sexual assault. Prophylactic treatment for chlamydia, gonorrhea, Trichomonasinfections, and bacterial vaginosis may be provided. Recommended regimens include: Ceftriaxone 125 mg IM in a single dose PLUS metronidazole 2 g orally in a single dose PLUS azithromycin 1 g orally in a single dose OR doxycycline 100 mg orally twice a day for 7 days.
  • Hepatitis B infection: Empiric treatment for hepatitis B with hepatitis B immune globulin (HBIG) following sexual assault is controversial. Its efficacy in adolescents who are already immunized against hepatitis B infection is unknown. The Centers for Disease Control and Prevention (CDC) recommends postexposure hepatitis B vaccine without HBIG as adequate protection against hepatitis B infection.
  • HIV postexposure prophylaxis (PEP): It is difficult to discuss PEP issues in the acutely traumatized victim. See Chapter 31 for more information and Web sites on PEP.
  • –First assess the risk for HIV infection in assailant and evaluate circumstances of assault that may affect risk for HIV transmission. PEP is best reserved for individuals at higher risk, that is, those who had penetration by an assailant known to be HIV positive or at high risk for HIV infection (men who have sex with men, injection drug users, men with recent incarceration).
  • –Consult a specialist in HIV treatment in your local area if PEP is considered.
  • If the victim is eligible for PEP, discuss antiretroviral prophylaxis including toxicity and unknown efficacy.
  • –If the victim accepts PEP, provide prescription for 7 days of medication and follow-up in 7 days to assess tolerance to medication.
  • Prevention of pregnancy: Emergency contraception may be provided without speculum examination. If the adolescent has not been using prescription methods of contraception, pregnancy prophylaxis should be discussed, that is, emergency contraception within 5 days of an incident. Although Plan B may be taken as a single dose medication, most other approved regimens require two doses. When these are prescribed, it is recommended that the adolescent receive her first dose with an antiemetic in the emergency room and the second dose 12 hours later. However, some hospitals and physicians do not prescribe emergency contraception on religious and ethical grounds. Therefore, if emergency contraception is indicated, it is very important that the provider refer the adolescent to a hospital that does dispense or prescribe emergency contraception.
  • Sleep aids: These can be prescribed if indicated but should be given in small quantities.
  • Medical follow-up: An appointment with a health care provider should be scheduled as indicated or within 14 to 21 days after the assault, especially in adolescents who have suffered penetration and penetrative injuries. A third visit may be scheduled at 8 to 12 weeks to repeat initial serological studies including tests for syphilis, hepatitis B, or HIV infection. The adolescent should be followed up and evaluated for psychological symptoms (i.e., post-traumatic stress disorder, depression, and/or anxiety). Health care providers should determine the appropriate supports and treatment required.
  • Psychological supports: Advocates, law enforcement representatives, and other responders can coordinate with the health care provider to discuss a range of issues before discharge from the emergency center. In many cities, rape crisis centers will send a supportive individual to the emergency department, if notified. The adolescent victim should ideally see a social worker or counselor trained in this area of work, before and after the medicolegal evaluation.
  • Areas to explore with the adolescent during the initial examination and follow-up are the following:
  • –Feelings during the assault.
  • –Feelings and worries regarding the rape, medical examination, and the legal process.
  • –Concerns regarding physical health, emotional reactions, sexuality, and unusual behaviors.
  • –Feelings regarding the perpetrator, family, peers, school, and job.
  • –Willingness to receive crisis intervention services (from professionals, paraprofessional, peers, religious, and other possible resources).
  • –Issues around her safety should be reviewed and she should be released to a caring friend or family member. Eligibility for protection orders and/or enhanced security measures should be assessed. Telephone numbers of rape hotlines or crisis centers should be provided as well.
  • –A follow-up appointment should be scheduled with a counselor.
  • Written materials: Written materials regarding victims' rights, the rape experience, reporting rape, feelings about rape, and special reactions (the teenage victim, male victim, and the disabled victim) should be given to the victim before leaving the hospital. Providers can obtain this information from Web sites and their local District Attorney's Office. In addition, most states and urban centers have resources and organizations dedicated to providing support for sexual assault victims. Web site resources including pamphlets for victims and their families are listed at the end of this chapter.

Sexually Transmitted Disease Transmission in Sexual Victimization of Adolescents

It is difficult to estimate the risk a sexually abused or assaulted adolescent has of acquiring an STD due to empirical treatment of syphilis, gonorrhea, and chlamydia at the time of sexual assault examinations. A major confounding factor is a report of prior consensual sexual activity by an adolescent at the time of the medical examination. As it stands now, the only determination regarding frequency and incidence that can be made is that bacterial STDs are more commonly isolated than viral STDs.

Factors that should be considered when determining STD risk include the duration between the genital examination and the reported event and pubertal development of a female adolescent. Adult male sex offenders may be at higher risk for STDs than males in the general population based on a history of multiple consensual and nonconsensual sexual encounters with both males and females. Moreover, males from correctional facilities are at higher risk for STDs and HIV infection (Beck—Sague et al., 1999).

When an infection has been determined, the possibility of nonsexual transmission, especially in a young adolescent, should be considered. Unlike for young children (below 3 years of age), nonsexual transmission of STDs through perinatal means is highly unlikely in adolescents. Transmission through fomites is also unlikely. In one controlled experiment,Trichomonas vaginalis was reported to

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survive in young girls who were bathing in tanks in India for religious rituals. This manner of transmission is highly unlikely in adolescents in the United States (Chacko, 2004).

Published studies on STD infection among sexually abused or assaulted adolescents have been predominantly determined from female samples. Neisseria gonorrhoeae has been isolated in 0% to 26.3% of cases, T. vaginalis in 0% to 19% of cases, Chlamydia trachomatis in 4% to 17% of cases, Treponema pallidum or syphilis in 0% to 5.6% of cases, and human papillomavirus (HPV) in 0.6% to 2.3% of cases. Of note, empirical treatment for T. vaginalis was not standard care at the time of sexual assault evaluations about a decade ago. Under these circumstances, trichomoniasis has been detected in 14.7% of victims in the emergency room visit, and an additional 13.8% at their 2-week follow-up; suggesting that this infection resulted directly from the incident (Reynolds et al., 2000). The literature on STDs in sexually abused or assaulted adolescent males is sparse. One study reported no STDs in any of the 80 males (including adolescents) evaluated for sexual abuse (Seigel et al., 1995). There is a limited number of reports of the occurrence of HIV infection in sexually assaulted adolescents, either male of female.

Little is also known about the infectivity of an STD organism after a single contact. In an adolescent who denies any prior sexual activity, the chance of isolating an STD on the day of an assault is low. It is also possible that such a positive test result would represent bacteria or virus present in the semen of the perpetrator. Emergence of an infection depends on the incubation period and varies depending on the specific organism. The incubation period and/or manifestation of symptoms of common STDs is approximately 1 to 14 days for N. gonorrhoeae urethritis in males and up to 10 days for cervicitis in females; 7 to 21 days for C. trachomatis in males and females; 10 to 90 days for T. pallidum (an average of 2–3 weeks for primary and 4–10 weeks for secondary lesions); 5 to 28 days for T. vaginalis; 2 days for herpes simplex virus lesions; and 4 to 6 weeks for HPV.

The anatomical site may also influence the likelihood of acquiring an STD in adolescent females. For example, because of the ability of N. gonorrhoeae and C. trachomatis to infect columnar epithelium of the cervix, penile–vaginal penetration may make acquisition of these STDs more likely as compared to penile-anal or oral penetration. In one case series, 4.6% of pubertal girls had N. gonorrhoeae—all were isolated from the cervix. Two had concurrent rectal gonorrhea and one had pharyngeal gonorrhea (Seigel et al., 1995). C. trachomatiswas isolated from the cervix in pubertal girls (Seigel et al., 1995). The less mature lining of the vaginal mucosa in a young premenstrual adolescent allows for easier occurrence of vaginitis by organisms like N. gonorrhoeae and C. trachomatis. Unlike bacterial STDs, HIV is more likely to be transmitted through anal intercourse.

The Investigative Process and Legal Outcomes

The effort to prosecute sexual assault perpetrators has its own requirements. A single, dedicated individual who can ensure an unbroken chain of evidence during the forensic examination and is able to follow through with detailed, immediate documentation is essential for providing factual testimony in court (U.S. Department of Justice, Office on Violence Against Women, 2004). In some areas, sexual assault nurse examiner (SANE) programs provide prompt access to emergency medical care by providing a dedicated examination room, a specially trained forensic examiner who is competent in collection of evidence for the investigation, expert witnesses, and a collaborative team approach. In large metropolitan areas, a community-based victim advocate can assist and counsel the victim and family (U.S. Department of Justice, Office of Justice Programs, Office for Victims of Crime Bulletin, 2001). In small towns and rural areas, such assistance is rarely available and is provided by the local law enforcement officer. Together, these factors can lead to successful prosecution.

Following the medical evaluation, the investigative process involves the following:

  • An interview of the victim by the police department if this had not occurred, so that charges can be filed. The police cannot investigate and pursue prosecution unless the victim is willing to talk to them.
  • Detaining the alleged perpetrator and evidence for an arrest reviewed. Following an arrest, the alleged perpetrator may be eligible to post bail. At this time, the victim may decide to drop charges and data suggest that charges were dropped in approximately half of cases where an arrest had been made (Gray—Eurom et al., 2002).
  • The prosecuting attorney will review the case. Since sexual assault is an offense against the state, the victim is a witness to the state and the state is the prosecuting party. The prosecuting attorney makes all decisions in regard to legal proceedings.
  • If the case goes forward, the prosecuting attorney will contact the victim to determine (a) whether the victim is willing to participate, (b) to evaluate the victim as a potential witness, and (c) to assess whether guilt can be proved beyond a reasonable doubt. Therefore, the ability of the victim to provide a detailed description of the event is vital.
  • The decision whether to prosecute is ongoing and is determined by several factors. Data suggest successful prosecution has been found to be significantly associated with victims who are <18-years-old, with the presence of genital trauma, and with the use of a weapon by the assailant (Gray—Eurom et al., 2002). Among sexually abused children, the conviction of the alleged perpetrators occurred in victims with normal or nonspecific findings of sexual abuse and in those who were older and reported penetration, pain, and blood when the event occurred (Adams et al., 1994). De Jong and Rose (1991) reported that the highest rate of felony convictions (83%) was in adolescent victims 12 years of age and older based on both the victim's description of the event and presence of physical findings. Therefore, the decision to proceed with criminal charges is often based on either physical evidence, the minor's ability to describe the abuse in detail, or both.

Testifying

  • Usually the provider first learns of a case going to court when he or she is subpoenaed or when the medical record is subpoenaed.
  • The provider needs to present the medical facts much like an expert witness. These skills are usually acquired through training and experience. A verbal explanation to acknowledge that the lack of physical evidence is

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  • not inconsistent with sexual penetration in child sexual abuse cases may be necessary.
  • Pretrial preparation is strongly encouraged and begins with the provider communicating with the prosecuting attorney after receipt of the subpoena. Some institutions prefer that the provider first seek guidance from an in-house attorney before contacting the prosecutor.
  • The provider should be prepared to discuss his or her educational background, qualifications, and clinical experience. It will be necessary to listen carefully and be guided by questions posed. Use of medical jargon should be avoided and terms and concepts should be explained in a straightforward and simple manner. Finally, the provider should avoid getting emotional and argumentative especially during cross-examination.

Web Sites

http://nccanch.acf.hhs.gov/. National Clearing House on Child Abuse and Neglect.

http://www.cdc.gov/ncipc/factsheets/svfacts.htm. CDC Sexual Violence Fact Sheet.

http://www.ncjrs.org/pdffiles1/ovw/206554.pdf. A National Protocol on the Sexual Assault Medical Forensic Examinations, Adults/Adolescents, 2004.

http://wwwusdoj.gov. U.S. Department of Justice, Office for Victims of Crime.

http://www.dhhs.gov. U.S. Department of Health and Human Services.

http://www.acf.dhhs.gov. The Administration for Children, Youth, and Their Families.

http://www.ndacan.cornell.edu/. National Data Archive on Child Abuse and Neglect.

http://www.childrensdefense.org. Children's Defense Fund.

http://www.cwla.org. Child Welfare League of America.

http://www.atsa.com. Association for the treatment of Sexual Abusers.

http://www.faithtrustinstitute.org/. The Faith Trust Institute.

http://www.youthlaw.org. National Center for Youth Law.

http://www.nsvrc.org. National Sexual Violence Resource Center.

http://www.menagainstsexualviolence.org/. Men Against Sexual Violence.

http://www.ncdsv.org/. National Center on Domestic and Sexual Violence.

http://www.usdoj.gov/ovw/. U.S. Department of Justice, Violence Against Women Office.

http://www.rainn.org/. Rape Abuse and Incest National Network.

http://www.4woman.gov/faq/sexualassault.htm. Department of Health and Human Services Sexual Assault fact sheet.

References and Additional Readings

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Adams JA, Botash AS, Kellogg N. Differences in hymenal morphology between adolescent girls with and without a history of consensual sexual intercourse. Arch Pediatr Adolesc Med 2004;158:280.

Adam JA, Girardin RN, Faugno D. Adolescent sexual assault: documentation of acute injuries using photo-colposcopy. J Pediatr Adolesc Gynecol 2001;14:175.

Adams JA, Harper K, Knudson S, et al. Examination findings in legally confirmed child sexual abuse: it's normal to be normal. Pediatrics 1994;94:310.

American Academy of Pediatrics, Committee on Adolescence. Care of the adolescent sexual assault victim. Pediatrics 2001;107:1476.

American College of Emergency Physicians. Management of the patient with the complaint of sexual assault. Ann Emerg Med 1995;25:728.

Anderson SC, Griffith S, Bach CM, et al. Sexual abuse of adolescent males: an overview. Paper presented at the Third international congress on child abuse and neglect;Amsterdam, The Netherlands; April 1981.

Anderson J, Martin J, Mullen P, et al. Prevalence of childhood sexual abuse experiences in a community sample of women. Am Acad Child Adolesc Psychiatry 1993;32:5.

Balsam KF, Rothblum ED, Beauchaine TP. Victimization over the life span: a comparison of lesbian, gay, bisexual, and heterosexual siblings. J Consult Clin Psychol 2005;3:477.

Bechtel K, Podrazik M. Evaluation of the adolescent rape victim. Pediatr Clin North Am 1999;46:809.

Beck—Sague CM. Sexual assault and STD. In: Holmes KK, Sparling PF, Mardh P-A, et al., eds. Sexually transmitted diseases, 3rd ed. San Francisco: McGraw-Hill, Health Professionals Division; 1999:1433.

Browne A, Finkelhor D. Impact of child sexual abuse: a review of the research. Psychol Bull 1986;99:66.

Bureau of Justice Statistics. Sexual Assault of Young Children as Reported to Law Enforcement: Victim, Incident, and Offender Characteristics. US Department of Justice. July 2000.

Catalano S. Criminal Victimization,2004. Bureau of Justice Statistics—US Department of Justice; 2005.

Centers for Disease Control and Prevention. Youth risk behavior surveillance, June 9, 2006. MMWR Morb Mortal Wkly Rep 2005;55(SS-5).

Centers for Disease Control and Prevention. Sexually transmitted diseases and guidelines 2006. MMWR 2006;55(RR-11):80.

Chacko MR, Staat M, Woods C. Genital infections in childhood and adolescence. In Feigin RD, Cherry JD, Demmler GJ, eds. Textbook of pediatric infectious diseases, 5th ed, Vol 1. Philadelphia, Pennsylvania: Saunders, an Imprint of Elsevier Science; 2003:562.

Chacko MR, Wiemann CM, Smith PB. Chlamydia and gonorrhea screening in asymptomatic young women. J Pediat Adolesc Gynecol 2004;17:169.

Committee on Adolescent Health Care. Adolescent acquaintance rape. ACOG Committee opinion. Int J Gynaecol Obstet 1993;42:209.

Cunningham RM, Stiffman AR, Dore P, et al. The association of physical and sexual abuse with HIV risk behaviors in adolescence and young adulthood: implications for public health. Child Abuse Negl 1994;18:233.

Danielson CK, Holmes MM. Adolescent sexual assault: an update of the literature. Curr Opin Obstet Gynecol 2004;16:383.

Deisher RW, Bidwell RJ. Sexual abuse of male adolescents. Semin Adolesc Med 1987;3:47.

De Jong AR, Emmett GA, Hervada AA. Epidemiologic factors in sexual abuse of boys. Am J Dis Child 1982;136:990.

De Jong AR, Rose M. Legal proof of child sexual abuse in the absence of physical evidence. Pediatrics 1991;88:506.

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Dewdney D. Treatment of physically abused adolescents. Semin Adolesc Med 1987;3:55.

Diaz A, Simatov E, Rickert VI. Effect of abuse on health: results of a national survey. Arch Pediatr Adolesc Med 2002;156:811.

Doan LA, Levy RC. Male Sexual Assault. J Emerg Med. 1983;1:45.

Dunn SF, Gilchrist VJ. Sexual assault. Prim Care 1993;20:359.

Emans SJ, Woods ER, Allred EN, et al. Hymenal findings in adolescent women: impact of tampon use and consensual sexual activity. J Pediatr 1994;125:153.

Farber ED, Joseph JA. The maltreated adolescent: patterns of physical abuse. Child Abuse Negl 1985;9:201.

Federal Bureau of Investigation. Crime in the United States, 2004, Uniform Crime Reports. U.S. Department of Justice; 1999: Available at www.fbi.gov/ucr.

Ferris LE, Sandercock J. The sensitivity of forensic tests for rape. Med Law 1998;17:333.

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Finkelhor D. Risk factors in the sexual victimization of children. Child Abuse Negl 1980;4:265.

Finkelhor D. Child sexual abuse: new theory and research. New York: Free Press; 1984.

Finkelhor D. Current information on the scope and nature of child sexual abuse. Future Child 1994;4(2):31.

Finkelhor D, Browne A. The traumatic impact of child sexual abuse: a conceptualization. Am J Orthopsychiatry 1985;55:530.

Finkelhor D, Ormrod R, Turner H. The victimization of children and youth: a comprehensive, national survey. Child Maltreat 2005;10(1):5.

Furey EM. Sexual abuse of adults with mental retardation: who and where. Ment Retard 1994;32:173.

Gagnon J. Female child victims of sex offenses. Soc Probl 1965;13:176.

Gans JE, Blyth DA, Elster AB, et al. Americas Adolescents: how healthy are they? Chicago: American Medical Association; 1990.

Glaser JB, Hammerschlag MR, McCormack WM. Sexually transmitted diseases in victims of sexual assault. N Engl J Med 1986;315:625.

Golding JM. Sexual assault history and physical health in randomly selected Los Angeles women. Health Psychol 1994;13:130.

Golding JM, Cooper ML, George LK. Sexual assault history and health perceptions: seven general population studies. Health Psychol 1997;16:4.

Goodyear-Smith FA, Laidlaw TM. Can tampon use cause hymen changes in girls who have not had sexual intercourse? A review of the literature. Forensic Sci Int 1998;94:147.

Greenfeld L. Sex offenses and offenders: an analysis of data on rape and sexual assault. Washington, DC: Bureau of Justice Statistics; February 1997.

Greydanus DE, Shaw RD, Kennedy EL. Examination of sexually abused adolescents. Semin Adolesc Med 1987;3:59.

Gray—Eurom K, Seaberg DC, Wears RL. The prosecution of sexual assault cases: correlation with forensic evidence. Ann Emerg Med 2002;39:61.

Guidelines for the interview and examination of alleged rape victims. A conjoint effort of the Committee on Evolving Trends in Society Affecting Life and the Advisory Panels of Obstetrics and Gynecology, Pathology, and Psychiatry of the Scientific Board of the California Medical Association. West J Med 1975;123:420.

Hampton HL. Care of the woman who has been raped. N Engl J Med 1995;332:234.

Hanson KA, Gidycz CA. Evaluation of a sexual assault prevention program. J Consult Clin Psychol 1993;61:1046.

Hickson FC, Davies PM, Hunt AJ, et al. Gay men as victims of nonconsensual sex. Arch Sex Behav 1994;23:281.

Holmes M. Sexually transmitted infections in female rape victims. AIDS Patient Care STDs 1999;13:703.

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