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RESPONSE PROTOCOL |
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This Protocol is written for use with adults. Minors are
persons under eighteen years of age. Unless otherwise
specified, the term “child” means “minor.” However,
evidence collection issues apply to adults and children.
The emotional, psychological, and physical response by
adults and children to a sexual assault may vary. |
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Under North Dakota law, any person of the age fourteen
years or older may contact for and receive examination,
care, or treatment for sexually transmitted
infections/diseases (STI’s) without permission, authority,
or consent of a parent or guardian. However, due to the
nature of the sexual assault, it is the 2001 Team’s
recommendation that when appropriate, a parent or guardian
be notified to assist with issues that may arise during
the exam and to support the minor after the assault. |
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Initial Law Enforcement Response |
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The responsibilities of the responding officer include
ensuring the immediate safety and security of the victim
and obtaining basic information about the assault in order
to apprehend the assailant. At the initial law enforcement
response stage, the primary considerations of the
responding officer should be: |
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The physical
and mental health of the sexual assault victim |
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Forensic
collection of evidence |
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Learning the
history of the assault |
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The responding officer should
convey to the sexual assault victim that all case
histories are important. The responding officer should
explain that the information provided by the sexual
assault victim may be vital to the apprehension of the
assailant and that the officer will relay pertinent
information to investigators and also to medical
personnel. If appropriate, this interview could be
conducted with medical personnel present. Details of the
sexual assault itself are not necessarily needed at this
point in the investigation. |
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The responding officer should
elicit: |
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A brief
description of injuries, if any, to the victim, and to the
assailant (e.g., was the assailant scratched by the
victim) |
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A brief
description of what happened (e.g., vaginal, oral, or anal
contact, attempted contact, etc.) |
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How the
incident began |
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Where the
assault took place (e.g., residence, open area, vehicle,
etc.) |
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The identify
(name) and/or description of the assailant(s), if known,
or of other persons known who may be able to identify the
assailant |
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Where the
assailant(s) live and/or works, vehicles used, or areas
frequented, if known |
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The direction
in which the assailant(s) left and by what means (e.g., if
by vehicle, obtain description) |
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Whether or not
a weapon was involved |
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Items taken
from or left at the scene by the victim or the
assailant(s) |
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Items used by
the assailant to conceal identity or biological evidence
(e.g., condom, mask, gloves, items used to wash |
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Whether the
victim has broken fingernails |
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Standard practice for sexual
assault evidence collection indicates 72 hours is the
optimal timeframe for the collection of evidence. However,
the determination to proceed with evidence collection
should be made on a case-by-case basis by law enforcement,
the medical team, and the advocate. |
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The investigating officer
should convey the following to the sexual assault victim: |
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The
importance of seeking an immediate medical examination
since injuries or STI’s can lead to more serious health
problems and can go unnoticed or appear at a later time.
The healthcare professional can answer questions and
provide information about STI’s and pregnancy. |
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The
importance of collecting and preserving potentially
valuable physical evidence prior to the hospital
examination. The officer should explain to the victim that
such evidence can be inadvertently destroyed by activities
such as washing/showering, brushing teeth/using a
mouthwash, douching, eating, drinking, urinating, and
defecating. |
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The
importance of preserving potentially valuable evidence
that may be present on clothing worn during the assault as
well as on bedding or the materials involved at the crime
scene. |
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information for the responding officer: |
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In all cases
involving children, notify Child Protective Services. See
Appendix F. |
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It is best
practice to inform the treating facility that you will
soon be arriving with or are sending a sexual assault
victim. |
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The officer
or the facility should notify an advocate from the local
Crisis Center to respond to the facility. See Appendix F. |
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If possible,
request that a change of clothing be brought along to the
treatment facility in the event the clothing the victim is
wearing will be collected for evidentiary purposes. |
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Wait in the
prescribed waiting area while the victim is being treated.
Remain at the treatment facility until the examination is
completed before making arrangements to conduct the more
in-depth interview with the victim. In some jurisdictions
the officer who accompanies the victim to the treatment
facility also conducts the in-depth investigative
interview. This interview should occur after the victim
has had the opportunity to wash and dress. |
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At the
treatment facility, the responding officer and the
hospital staff should share with each other the available
information about the assault that may assist in the
examination, the evidence collection procedures, and the
criminal investigation. |
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Treatment Facilities |
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It is advantageous for all
victims of sexual assault to seek both medical treatment
and evidence collection from a health care facility that
has Sexual Assault Evidence Collection Kits from the Crime
Laboratory Division of the North Dakota Department of
Health. |
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Private medical offices or
local clinics are not open on a 24hour basis. They
generally do not have Sexual Assault Evidence Collection
Kits on hand. Moreover, they may not be as familiar as
hospitalbased sexual assault examiners with the specific
medical and evidence collection procedures relevant to
sexual assault victims. |
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Facilities providing sexual
assault treatment should have a 24hour emergency room
facility with staff trained in sexual assault
examinations, the oncall availability of a Sexual Assault
Nurse Examiner (SANE) or a specially trained physician for
consultation, the services of a local sexual assault
victim advocate and/or hospital support persons, and
contingency plans for cases requiring photographs and
bite-mark impressions. |
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In some areas of the North
Dakota, specially trained nurses are responsible for
evidence collection, immediate and follow-up medical care,
and community referrals and expert testimony. These Sexual
Assault Nurse Examiners (SANE) are working with treatment
facilities, law enforcement, and advocacy groups 24 hours
a day, seven days a week. |
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Transfer |
If a victim of sexual assault
arrives at a hospital that is not equipped to provide a
sexual assault examination, arrangements should be made to
transfer the victim to the nearest designated treatment
facility. However, if there are acute medical or
psychological injuries that must be treated immediately,
this should be done at the initial receiving facility. A
copy of all records, including any Xrays taken, should be
transported with the victim to the designated treatment
facility.
Transfer plans should be developed in conjunction with
other treatment facilities in the immediate and
surrounding community. Compilation of a North Dakota
treatment facility list will provide an excellent
opportunity for local hospital, law enforcement, and
support personnel to meet and discuss transportation
issues and other mutual concerns involving treatment and
followup policy. The list of designated hospitals should
then be provided to all local law enforcement agencies and
victim advocacy organizations. This can be compiled
locally with lists distributed to local personnel.
Developing this list will greatly reduce the amount of
confusion and additional trauma incurred by those victims
who are initially taken or referred to a nontreatment
facility, as well as reduce the loss of valuable evidence.
Local law enforcement offices, hospital personnel or
support personnel may consider setting up a Sexual Assault
Response Team (SART). The 2001 State Team recommends that
each local team work together to address the issues of
sexual assault in their area and to know what resources
are available to them. |
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Intake |
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The treatment of victims of
sexual assault should be considered a medical emergency.
Although many victims may not have visible signs of
physical injury, they will, at the very least, be
suffering from some type of emotional trauma. |
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If at all possible, a private
location within the hospital should be utilized for the
preliminary consultation with the victim. This could be a
room adjacent to the emergency department, the examination
room, or private office located nearby. It is recommended
that this same space be used for the follow-up law
enforcement interview at the conclusion of the examination
in order to provide privacy. A victim must be allowed to
wash and dress prior to the in-depth investigative law
enforcement interview. |
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Over the past several years,
many hospitals have developed "code" plans, such as "Code
R" or "SA" to use when referring to sexual assault cases.
This eliminates the needless embarrassment to victims
and/or their families of being identified in the public
emergency or examining room setting as the "rape" or
"sexual assault" victim. Other methods can be devised to
avoid inappropriate references to sexual assault cases.
Treatment facilities are encouraged to develop their own
sensitive code plans to ensure privacy. |
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Reporting |
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Victims of sexual assault will
need the assistance of all team members to be able to make
informed decisions about reporting a sexual assault.
Helping the victim understand both the positive and
negative consequences of their decision to report or not
report the sexual assault is important. |
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North Dakota has mandated
reporting laws for violent crimes, including sexual
assault. These laws specify that local law enforcement
authorities shall be routinely notified by hospital
personnel as soon as is practicable. See Appendix I. |
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Mandatory Reporting by
Professionals |
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Pursuant to N.D.C.C. §
43-17-41, any physician, physician assistant, or any
individual licensed under N.D.C.C. Chapter 43-12.1 who
performs any diagnosis or treatment of any individual
suffering from any wound, injury, or the physical trauma
that is inflicted with a knife, gun or pistol is required
to report the act to a law enforcement agency in the
county in which care is rendered. The same medical
personnel who performs any diagnosis or treatment of any
individual in which there is reasonable cause to suspect
the wound or injury was inflicted in violation of any
criminal law of the State are required to report the
injury to a law enforcement agency. This applies to sexual
assault. Therefore, the same medical personnel must report
any suspected sexual assault. This does not apply to
mental health professionals, clergy or others providing
services not related to the physical injury of a crime
victim. |
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North Dakota law mandates the
reporting of suspected child abuse and neglect, and abuse
and neglect of vulnerable adults. Physicians, nurses,
dentists, optometrists, medical examiners, coroners or any
other medical or mental health professional, religious
practitioner of healing arts, school teacher or
administrator, school counselor, social worker, daycare
center or any other care provider, law enforcement
officers or members of the clergy having knowledge or
reasonable cause to suspect abuse or neglect are required
to report pursuant to N.D.C.C. § 50-25.1-03 and N.D.C.C. §
50-25.2-03. |
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See Appendix I. |
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Victim Reporting of Sexual
Assault |
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The Crime Victims Reparation
Program should be consulted for information regarding the
cost of medical treatment and related expenses. Victims of
criminal activity are eligible for victim compensation
awarded by the State. Pursuant to N.D.C.C. § 54-23.4-16,
victims of injury or death in relation to a crime must
report to a law enforcement officer within 72 hours after
the occurrence of the crime. The claimant must also fully
cooperate with appropriate law enforcement agencies or may
be denied, reconsidered, or have a reduction in the award
of compensation. |
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For more information about the
Crime Victim Reparation Program call (701) 3286195 or
18004452322. See also Appendix G. |
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Support Personnel |
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It is highly important that an
advocate or support person be available to sexual assault
victims. Whenever possible, one support person should be
assigned to stay with the victim throughout the entire
emergency department visit. |
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Well-trained support persons
can provide the crisis intervention necessary when victims
first arrive for treatment. They can also counsel family
members or friends of the victim who may be at the
treatment facility. Support persons can help provide
counseling referrals and other information, such as the
existence and availability of victim compensation programs
or other types of assistance and can emphasize the
importance of follow-up testing for possible sexually
transmitted infections or other medical problems. They can
also answer additional questions victims may have. |
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Some treatment facilities are
fortunate enough to have in-house staff specially trained
to treat victim trauma and who can provide crisis
intervention for sexual assault victims and their
families. Some of these staff members are also qualified
to provide follow-up counseling to victims on a short or
long-term basis. |
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Local sexual assault victim
organizations provide crisis intervention services for the
victim and the family from during the medical exam, the
investigation, and the criminal justice process. An
increasing number of communities throughout the state have
resources for follow-up counseling. These organizations
may provide immediate crisis intervention to victims who
have arrived at the hospital seeking treatment, as well as
follow-up counseling and referrals. In some instances,
they also provide support for the victim throughout the
entire criminal justice process. |
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See Appendix F. |
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Victim Consent to Evidence
Collection and Release |
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Obtaining a sexual assault
victim’s fully informed written consent prior to
conducting a medical examination or administering
treatment is the standard practice of medical treatment
facilities. Medical treatment facilities should follow
their usual procedures for obtaining consent in
extraordinary cases, e.g., for severely injured or
incoherent victims. |
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Informed consent should be a
continuing process that involves more than obtaining a
signature on a form. When under stress, many victims may
not understand or remember the reason for or significance
of unfamiliar, embarrassing and sometimes intimidating
procedures. Therefore, all procedures should be explained
as thoroughly as possible, so that the victim can
understand what is being done and why. Although much of
the examination and evidence collection process can be
explained by the advocate or support person, or law
enforcement, this is ultimately the responsibility of the
medical treatment facility personnel. |
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Having a sense of control is
an important part of the healing process for victims,
especially at the early stages of examination and
interviewing. When written consent is obtained, it should
not be interpreted as a "blank check" for performing tests
or questioning the victim. If the victim expresses
resistance or non-cooperation, the attending medical
personnel should immediately discontinue that portion of
the process and consider going back to it at a later time
in the examination if the victim then agrees. The victim
has the right to refuse one or all tests and/or to refuse
to answer any question. |
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The victim should converse
with an advocate so that he or she can determine whether
they would like to use advocate services and to understand
that she or she may request an advocate at any time during
the process. At any time during the treatment and evidence
collection process, the victim should be able to refuse
further interaction with the designated advocate or
support person and/or request that the support person
leave the treatment area. |
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Drugs and Sexual Assault |
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Perpetrators may use drugs to
facilitate a sexual assault. Examples of drugs used
include Rohypnol, Gamma Hydroxybutyrate (GHB), Ketamine,
PCP, Valium, and Haldon. These drugs can leave a victim
completely incapacitated. When combined with alcohol, the
effects are multiplied and can be deadly. |
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Rohypnol, generically
Flunitrazepam, is a benzodiazepine prescribed as a
sleeping pill. This drug is similar to Valium, but
approximately 10 times stronger. It is the most widely
prescribed sedative in Europe but is not licensed for sale
in the United States. Rohypnol is produced by
Hoffmann-LaRoche, a pharmaceutical company in Mexico. The
illicit use of Flunitrazepam is characterized by its use
with other drugs, although it may be used alone. It
enhances the high produced by low quality heroin. In the
United States, it appears to be used most frequently in
conjunction with alcohol. Rohypnol causes muscle
relaxation, slow psychomotor responses, and lowers
inhibitions. When taken in high doses or in combination
with alcohol, it causes complete blackouts combined with
amnesia for eight to twelve hours. Because routine
benzodiazepine screens do not detect its presence and
traces in the blood and urine may be only be detected for
up to 8 to 12 hours after ingestion, it can be used while
avoiding drug charges. Rohypnol is growing in popularity
among high school and college age individuals. Street
names include rophies, roofies, ruffies, R2, roofenol,
Roche, roachies, la rocha, rope, and rib. It is known to
be sold at nightclubs, bars, and/or college fraternities
or sororities in the United States for two to five dollars
per tablet. Other benzodiazepines that may be used include
Alprazolam (Xanax), Clonazepam (Klonopin), Diazepam
(Valium), Flurazepam (Dalmane), or Lorasepam (Ativan). |
Gamma Hydroxybutyrate (GHB) is
a fast acting central nervous system depressant. It is a
colorless and odorless liquid with a salty taste. It is
also used in powder and capsule forms. This drug has been
used in Europe to induce short-term comas, for surgical
anesthesia, as a treatment for narcolepsy, and in the
withdrawal of alcohol and opiate addictions. This drug has
not been approved for sale as a medical product in the
United States. GHB intensifies feelings of intoxication
and may result in decreased inhibition. It produces a
similar feeling to alcohol intoxication. Its effects are
exacerbated by combining it with alcohol. The effects can
occur within 15 minutes to one hour of ingestion. It may
cause nausea, drowsiness, respiratory distress, dizziness,
seizures, and amnesia. GHB has been marketed as a health
food product for its hypnotic effects and also to promote
weight loss and muscle development. It has been sold over
the counter as a dietary supplement. Street names of GHB
include liquid ecstasy, grievous bodily harm, Georgia home
boy, liquid X, liquid E, soap, scoop, easy lay, salty
water, cherry meth, zonked, somotomax.
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If it is believed that an
individual has been drugged to facilitate sexual assault,
a urine collection sample should be obtained immediately.
It is recommended that a State Toxicology Collection Kit
from the Crime Laboratory Division of the North Dakota
Department of Health be used to perform this procedure. |
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If victims state they cannot
remember events and/or feel as though they are hung over,
even though reporting the absence of or low alcohol
intake, further medical evaluation and testing for the
presence of these drugs may be necessary. In a
drug-facilitated rape case, the likelihood of detecting
the drug used to commit the rape diminishes each time the
victim urinates. Therefore, it is imperative that
immediate action be taken to preserve the evidence. |
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There are two very important
concepts the attending medical personnel need to be aware
of regarding drugs and sexual assault. First, it should
never become routine to collect drug screens on sexual
assault victims. Second, the victim needs to give informed
consent to the collection of a sample for a drug screen.
The victim needs to understand that a urine sample may
show positive for illegal or prescription drugs that he or
she has taken during the previous several days. |
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There are several indications
that should cause the attending medical personnel to
suspect a drug-facilitated rape. For instance, the victim
may give a history of having only one or two drinks and
suddenly feeling “very drunk.” The victim may become
highly intoxicated within a matter to 5 to 15 minutes,
especially after receiving a drink form someone or leaving
her drink unattended. Some victims have reported “cameo
appearances” where she recalls awakening and seeing the
perpetrator, but is unable to move and loses consciousness
again. The victim of a drug-facilitated rape may exhibit
signs of memory loss, dizziness, confusion, drowsiness,
impaired motor skills, impaired judgment, reduced
inhibition or a variety of other symptoms. The victim may
appear intoxicated or “hung over.” Depending on the
timeframe and circumstances, some of these symptoms may
still be present when the victim speaks with attending
medical personnel. |
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If the attending medical
personnel suspect a drug-facilitated rape, he or she
should follow this procedure: |
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Explain your
suspicions to the victim and the need to collect a sample
for a drug screen. |
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Inform the
victim that the drug screen can report positive for any
legal and illegal substances ingested within the previous
several days. |
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Explain to
the victim that he or she may refuse the drug screen. |
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Determine
whether INGESTION of the drug occurred with in the
previous 72 hours. If so, IMMEDIATELY collect a urine
specimen as specified below. |
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Collect 100ml
of urine in a sterile container. If it is not possible to
collect 100ml, at least 30ml should be collected. If a
State Toxicology Kit is not available, urine may be
collected in a sterile urine specimen container from
hospital stock. The container must then be sealed and
labeled with the victim’s name and the date/time of
collection, placed in a ziploc or plastic bag (to avoid
leaks), and then placed in the Sexual Assault Evidence
Collection Kit box. Indicate on the documentation provided
in the Kit that a drug-facilitated rape is suspect. |
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Immediately
refrigerate the specimen maintaining appropriate
chain-of-custody procedures. |
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Document (a)
the estimated date and time the suspected drug ingestion
occurred; (b) how many times the patient urinated since
the estimated time of ingestion; and (c) whether the
patient has been taking any prescription or
over-the-counter medications during the previous 4 to 5
days, and if so, the names of these medications and the
dates and times they were taken. |
