A 16-year-old female presents to the emergency department (ED) after being sexually assaulted by two males at a party at her friend’s house. She denies any complaints or injuries. She is asking for an exam, as well as medications to avoid pregnancy and diseases. She refuses to allow her parents or the police to be notified. What do you do?

Discussion

The answer to that question varies with your practice location. Federal and state laws dictate what actions you will take in this scenario. The key to answering this question, no matter where you are, is to engage your hospital attorney or risk manager. They are very familiar with the laws in play in these scenarios and can easily work with you throughout the process.

First, the federal Violence Against Women Act (VAWA), 42 USC.A § 3796gg-4(d)(1) (2005), allows for sexual assault survivors to undergo medical forensic examination without reporting to law enforcement and at no cost to them. VAWA specifies which components must be included in the exam for free. Failure to follow these forensic compliance provisions of VAWA can result in loss of funding for your state. Sexual assault nurse examiners (SANE nurses) are very familiar with the options available to patients regarding reporting to law enforcement and evidence collection. They should be consulted to assist in the discussion with the patient.

Reporting to Law Enforcement

The first decision is whether your state requires you to report sexual violence to law enforcement. Some states mandate that certain crimes, including rape and sexual assault, must be reported to law enforcement regardless of the wishes of the patient. If you must report, you can tell the patient that, “by law I must report to law enforcement that you are here because of a sexual assault, however, you are under no obligation to talk to them and can tell them you do not wish to speak to them.”¹

Age of Patient

The next consideration is the age of consent in your state. If the patient is under the age of consent, you may be a mandated reporter. Therefore, you may be obligated to report the assault both to law enforcement and to child protective services. Even if the patient is above the age of consent, as a mandated reporter you may need to still notify authorities in cases where the perpetrator is a parent, guardian, family member, coach, teacher, or someone who may have regular contact with the patient. Once again, you should inform the patient of your duty, under the law, to report the assault to law enforcement and child protective services.

Consent for Care

The final consideration in this case is the patient’s ability to provide consent for care. Usually, the teenaged patient needs parental consent to seek care in the ED unless it falls under the emergency-consent exception. The exception is based on the premise that a reasonable person would not want to be denied necessary medical care because they were too incapacitated to consent to the treatment. This usually applies to potentially life- or limb-threatening conditions. Many states specifically authorize minors to consent to contraceptive services, testing and treatment for human immunodeficiency virus and other sexually transmitted diseases, prenatal care and delivery services, treatment for alcohol and drug abuse, and outpatient mental health care, without parental involvement or consent. Each state has different nuances within these categories and legal consultation can be crucial in the ED when dealing with these issues.

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Case Resolution

You place a call to your on-call hospital lawyer. The state does not require mandatory reporting of sexual violence, and the age of consent is 16 years of age. In addition, the ages of the perpetrators do not fall under the mandated-reporter statute. The SANE nurse is consulted, and she is able to discuss the reporting options available; the patient chooses to do an anonymous report with evidence collection. Lastly, because she is seeking care around a sexual health/sexually transmitted infection issue, you are able to treat her without parental consent.

Dr. Rozzi is an emergency physician, director of the Forensic Examiner Team at WellSpan York Hospital in York, Pennsylvania, and chair of the Forensic Section of ACEP.

Dr. Riviello is chair and professor of emergency medicine at the University of Texas Health Science Center at San Antonio.

Reference

1. Bailey C, et al. Mandatory reporting and adolescent sexual assault. Trauma, Violence, & Abuse. 2023;24(2):454-467.