A2. Adapting Care for Each Child



These recommendations are for all responders to adapt care to address each child’s needs.

Adapt care to each child’s needs and circumstance. Gathering information about a child victim’s circumstance allows responders to provide customized interventions that meet the child’s needs, as well as investigative needs. Understanding the child’s circumstance includes looking at obvious facts (e.g., the child’s developmental level, the nature of the sexual abuse experienced, and child’s reactions to it) and beyond those factors (see the table below). The goals are for responders to acknowledge and appreciate the whole child and be sensitive and inclusive in their interactions with each child.

Examples of Differences in Circumstances for Child Victims

Characteristics/Background

  • Age and developmental levels
  • Family: caregivers, siblings, and others living with the child in the home
  • Residence, including homelessness and institutionalized settings
  • Preferred communication method
  • Language needs for limited English proficient children, those who are Deaf and hard of hearing, and those with disabilities that affect communication (also consider language needs of accompanying caregiver)
  • Sex
  • Gender identity or expression
  • Sexual orientation
  • Physical health history and current status
  • Mental health history and current status
  • Disability status and type of disability
  • Ethnic and cultural beliefs and practices
  • Religious and spiritual beliefs and practices
  • Economic status
  • Immigration and refugee status of child and family, including recent and undocumented
  • Military status of family
  • If there is a history of victimization
  • If there has been exposure to violence in the home
  • If there has been exposure to substance use in the home
  • Experience with the juvenile justice, criminal justice, and/or child protection systems
  • Tribal affiliation of child and family

Sexual Abuse Experienced

  • Type(s) of acts, frequency
  • Number of perpetrators
  • Relationship with perpetrator(s)
  • Where the abuse occurred
  • If it involved drugs and/or alcohol
  • If photographic images of the abuse were taken/distributed
  • If there was exposure to pornography
  • Whether physical injuries were sustained from the abuse and the Frseverity of injuries
  • Concerns regarding STDs, including HIV
  • Child’s reactions to the sexual abuse
  • Concerns about safety and continued violence
  • Level of caregiver/family support available to facilitate child safety and healing
  • Strengths child and family bring to healing process

Community/Societal Issues

  • Community/cultural attitudes about child sexual abuse, its victims, and perpetrators
  • Frequency of sexual abuse and other violence in the community and historical responsiveness of the justice system, health care systems, and service agencies to it
  • Accessibility of relevant community resources/services for children from different populations and settings

Do not press children or caregivers for this information during the exam process beyond what is essential for providing medical forensic care (See B5. Medical History). It is inappropriate to ask about some information, such as immigration status or sexual orientation. It is more important to be guided by what children and caregivers self-identify, as well as what is observed (avoiding subjective interpretation of behavior observed).


Child victims have varying levels of tolerance for interacting with multiple unfamiliar adult responders. Some children may become irritable (especially younger children who are used to a routine schedule), frightened, or overwhelmed. Building rapport with children from the first interaction is critical to increasing their comfort level. (See below for communication strategies).  

Assess these fundamental communication issues early in the exam process in each case:

  • Evaluate children’s development level so that appropriate language is used. Developmental level and language skills and preferences must be factored into responders’ decisions regarding how to build rapport with children, as well as the scope of information that is communicated to and sought from them (See B5. Medical History). Literacy of prepubescent children also must be considered when offering material (e.g., pictures may be more appropriate than words for younger patients).
  • Identify if there is a need for language assistance or other accommodations to allow a child and/or caregivers to clearly and fully communicate with responders during the exam process. To facilitate provision of language assistance and communication-related accommodations, health care facilities and other responding agencies should have policies in place to (1) work with children and caregivers to identify if a need exists for such services and, if so, to determine specific needs; and (2) arrange for those services (e.g., specifying who and how to contact, what should happen once a request for services is made, and who can approve the cost of securing these services). Agencies and facilities should develop service agreements with those providing language access and accommodation services in order to provide prompt access when needed. At a minimum, agreements should specify: protocols for requesting services; response time to such requests; who will provide services (certified and qualified individuals); how to determine if a particular service provider is a good fit for a case; and personnel training needed prior to service provision.

NOTE: See below for more discussion on arranging language services and other communication accommodations. Pages 35-36 provide “Tips for Arranging Language Services” and page 37 provides “Tips for Arranging Other Communication Accommodations.” 

Tips for Arranging Language Services
  • Recognize that health care facilities and providers generally are subject to federal civil rights laws for language access services to ensure meaningful access for limited English proficient (LEP) individuals and effective communication services for persons who are Deaf or hard of hearing, including the use of qualified bilingual staff, interpreters, and translators (The Joint Commission on Accreditation of Healthcare Organizations [The Joint Commission], 2010).[1] These laws are incorporated into the Joint Commission’s standards.[2]
  • During the examination, use appropriate bilingual/multilingual examiners or provide monolingual examiners with support from certified interpretation services and translated materials for children and caregivers who are not proficient in English, are LEP, or who may prefer to communicate in a non-English language. Sign language services may be needed for children and caregivers who are Deaf or hard of hearing—American Sign Language (ASL), Signed English, or, for patients who are Deaf or hard of hearing and are LEP, sign language services in their language of origin. [3]
  • Let children and caregivers specify individual preferences of style and language of oral and written communications. Ask: “What is your preferred way to communicate?” “What is the best way for us to communicate with you?” Adapt questions as needed to be developmentally appropriate for a child. Language identification cards and posters are sometimes used to help responders determine a person’s preferred language. The goal is clear and full communications; limited communication is insufficient.
  • Use certified and qualified interpreters and translators.[4] Certification usually indicates that a person has met the minimal requirements of an accrediting body (usually a state or national organization) for providing interpretation and/or translation services in a specific language. There are also more specialized certifications, such as for medical or legal interpretation and translation services. In addition to being certified, interpreters and translators must be qualified for the assignment of working with prepubescent children and caregivers in sexual abuse cases. They should be educated on: the basics of communication with children and adults, child sexual abuse, and the medical forensic examination; confidentiality requirements; words and phrases used during the exam process; and language that will allow them to sensitively and respectfully talk about sexual abuse and related health care and legal issues with children and adults. They should understand that, although it is unlikely, they may need to testify in a case. Qualification for a particular assignment may be further influenced by interpreter/translator skill set and experiences (e.g., in working with individuals with disabilities that affect speech), child or caregiver needs (e.g., some children may not be comfortable with interpreters or translators of the opposite sex), and prior connection to those involved in the case (this issue is discussed below). Also, country of origin, acculturation level, and dialect of children and caregivers must be taken into account when selecting interpreters and translators. For example, a Spanish-speaking Cuban interpreter may encounter language and trust obstacles when communicating with a child and caregiver from rural Mexico (Zarate, 2003).
  • To increase access to certified, qualified interpreters and translators, health care facilities and other agencies responding to child sexual abuse are encouraged to create multilingual staffing opportunities as well as develop working relationships with external language services. Multilingual staff’s interpretation abilities should be assessed by the facility/agency rather than relying solely on a person’s self-identification as multilingual.
  • In each case, use interpreters and translators who are neutral third parties and do not have a prior relationship with the child, the family, or the perpetrator, if known. Do not use the child’s caregivers, family members, or friends as interpreters or translators. Their use could result in unreliable communication as well as jeopardize the admissibility of statements in court. It may be difficult for them to adopt a neutral stance or to avoid interjecting their own thoughts in the conversation.
  • Recognize that in rural and remote areas especially, there may be limited access to certified and qualified interpreters and translators. In addition, when they are available, it is possible they may have prior connections to the child, family, and/or perpetrator, if known. Pediatric examiners and multidisciplinary response teams in these regions should brainstorm strategies to secure access to a pool of certified and qualified interpreters and translators in the languages predominant and emerging in the area, with interpreters and translators in the pool having limited connections to the local community.
  • Be aware that for specific languages, especially those not frequently used in a community, it may be difficult to identify face-to-face interpreters and translators who are certified and qualified AND who do not have prior connections to the child, family, or perpetrator, if known. Although less preferable than face-to-face services, phone and video remote interpretation services may be an option in some instances. Examiners and other involved responders need to assess if remote interpretation services are appropriate and would be effective in an individual case, taking into consideration issues such as logistics of service provision, confidentiality, comfort level of the child and caregiver with such services, interpreter competency in providing remote services, etc. Note that remote interpretation may be inappropriate to use with certain populations—for example, individuals who are Deaf and hard of hearing.
  • Make sure space is available for those assisting with language needs during the exam process. Consider the best location for these service providers in relation to the child, both to respect the child’s privacy and modesty and to allow optimal communication. The location used should also be well lit.
  • If forms and materials are not available in a language or format that is accessible to a child or caregiver in a case (accessible information is preferred), engage a translator to assist in sight translation. If the child or caregiver is blind or has low vision, forms and materials may need to be read aloud. If the child or caregiver has intellectual disabilities,[5] information from forms and materials may need to be translated into plain language[6] and/or pictures to convey meaning. As with interpretation, accurate translation of information is crucial given its emotional, medical, and legal implications.
  • Make interpreters and translators aware that these assignments have the potential to be traumatic for them, particularly if they have a history of sexual victimization. Outlets should be available to them to promote self-care and address vicarious trauma they may experience in the course of service provision. In addition to helping prepare a pool of interpreters and translators for their role in the exam process, responding agencies/facilities and multidisciplinary response teams could invite them to participate in related programming they may offer.

Tips for Arranging Other Communication Accommodations
  • Do not assume children with disabilities affecting communication will need specialized assistance. Explain exam procedures to children and caregivers and ask what specific help might be necessary, if any, to accommodate their communication needs. The goal is for children to be able to fully participate in and benefit from the examination—responders should be clear that they strive for this goal with every child, regardless of their ability/disability, and it is standard practice, rather than an inconvenience, to arrange accommodations needed.
  • Recognize that there is a range of assistive and augmentative communication tools, devices, and services that may benefit persons with sensory disabilities (speech, vision, and hearing), including but not limited to video phones, word boards, speech synthesizers, anatomically detailed dolls, materials in alternative formats (large font, Braille, audio file, plain language, etc.), and interpreter and translation services. Become familiar with the basics of communicating with individuals using these tools, devices, and services. Note that individuals may have their own assistive devices, but words needed to communicate may have to be programmed. Avoid assumptions about which technology is appropriate for an individual based on her/his disability (e.g., do not assume that just because a person is Deaf or hard of hearing, she/he will understand sign language or can read lips, or that if a person is blind, she/he can read Braille). Work with each child and caregiver to determine what tools or services are appropriate. [7]
  • In general, children who use assistive or augmentative tools and devices depend on them (these tools and devices may be viewed by children as extensions of themselves). If these tools or devices are considered as forensic evidence in a case, they can be swabbed and photographed with the same intent and process used to collect and photo-document forensic evidence from the body, but they should not be taken away from the child.[8]
  • Recognize that for all children, including those with disabilities, the option to have a support person present during the exam process might increase their willingness to engage with responders. For example, a child with an anxiety disorder who is fearful and worried may be comforted by the presence of a caregiver, a victim advocate, or a child life specialist, which in turn may reduce the child’s hesitancy to interact with the examiner (For more on considerations related to support persons in the exam room, see B5. Medical History and B7. Examination).

 

 

Although it is impossible to know all cultural and linguistic issues that may impact the care of any individual child, take general measures to promote culturally and linguistically appropriate care during the exam process (Weaver, 2013). A few key actions are offered below (adapted from Weaver, 2013):

  • Recognize that everyone has biases that can negatively impact their ability to provide high-quality care for all children. Work to overcome personal biases.
  • Consider how historical oppression (racism, sexism, ableism, audism,[9] classism, homophobia, religious persecution, etc.) can impact care provided and identify approaches to create conditions that are more just for all children served.[10]
  • Understand that each person is multicultural, bringing a blend of cultural and linguistic considerations. View multicultural identity of children and family members in these cases as a potential strength they can draw upon to cope with adversity in their lives, care for one another, and heal, rather than seeing another’s cultural beliefs and practices as only presenting challenges to the response process.
  • Provide the type of care preferred by each child. 
  • Recognize that evidence-informed care is only as good as the diversity of populations sampled for research and that it needs to be balanced with child-focused, victim-centered, and trauma-informed principles of care. [11]


Generally speaking, CULTURE is a body of learned beliefs, traditions, and guides for behaving and interpreting behavior that is shared among members of a particular group (Blue, n.d.). In this protocol, a cultural group refers not only to ethnic or racial groups, but also other groups with distinct cultures. Examples include faith communities; Deaf and hard-of-hearing communities; lesbian, gay, bi-sexual and transgender individuals; immigrants; refugees; the homeless; military personnel and their dependents; and individuals in detention settings, foster care systems, boarding schools, and other residential settings. One culture may be closely connected to another (e.g., an ethnic group may be rooted in religious and/or spiritual beliefs of a particular faith community). Individuals often belong to multiple cultural groups. Note that cultural beliefs may or may not affect a child’s experience of sexual abuse, the related reactions of the child and caregiver, and preferred approaches to emotional support, healing, and justice (adapted from DeBoard-Lucas et al., 2013). If culture is influential in this regard, responders can offer to help children and caregivers to access cultural resources during the exam process and beyond.

Consider general communication strategies that can help build rapport with children across populations and facilitate culturally and linguistically appropriate care (see below). Building rapport with the child is essential not only to the effectiveness of the exam process, but also in reinforcing for children that there are adults who are safe and can be trusted. Ultimately, the message that responders should seek to convey is that all children deserve respect and are capable of healing from the abuse.

General Communication Strategies[12]
  • Introduce yourself to the child and your role in exam process.
  • Ask children their preferred name (“What would you like me to call you?”) and greet them as such. If pronouns are used, use ones the child prefers—use the child’s choice of language (it is important for responders to be aware that transgender and gender non-conforming people exist and to allow children to define their own gender[13] ).
  • Begin by discussing things other than the reason for their visit (e.g., schools, pets, siblings, and likes/dislikes).
  • Have a calm demeanor. Avoid the appearance of being rushed.
  • Speak at the child’s eye level or below.
  • >Maintain eye contact with the child if culturally appropriate.
  • Speak directly to the child, even when a caregiver or interpreter is present or the child is nonverbal.
  • Be clear, concise, and exact in explanations. Ask concrete rather than vague questions.
  • Be empathetic and nonjudgmental. Believe the child.
  • Avoid verbal language that might convey you are blaming the child for the abuse (e.g., “girls your age need to wear more than underwear around male relatives”).
  • Avoid body language that might indicate you are judging the child (e.g., cringing when the child reveals she/he engaged in survival sex, is transgender, or was used in sadomasochistic acts).
  • Avoid making assumptions about nonverbal behavior of children.
  • Avoid making assumptions about the way the child feels about the perpetrator and acts of sexual abuse (and do not talk disparagingly to the child about the perpetrator).
  • Seek to learn about and reflect the child’s language (e.g., for body parts[14] ).
  • Do not touch the child without permission.
  • Allow the child to participate in and make choices during the exam process, to the extent possible (e.g., ask the child “What color blanket would you like?” “How are you doing now?” “Are you ready to do the next thing?”).
  • Affirm the child throughout the process, while offering information and opportunities for questions (e.g., “You did a great job with that part of the visit. Here is what is coming up next. Do you have questions about what is happening?”).
  • Explain what information gathered during the exam process will be shared with others (e.g., caregivers and the investigative team) and when it will be shared, and be open to discussing any related concerns (See A5b. Confidentiality and Release of Information).
  • Do not pressure the child to respond to questions or agree to exam procedures.

Children’s communication skills, attention, and tolerance for interacting with responders may quickly deteriorate if they are feeling traumatized, tired, apprehensive, anxious, irritable, hungry, thirsty, distracted, uncomfortable, or negatively judged, or if they perceive their concerns are being minimized. For each child, consider what measures might aid in sustaining optimal communication with responders throughout the exam process. Acknowledge any apprehension the child has about the exam process or seeking help in general, and discuss what would help her/him be more comfortable.

On an ongoing basis, seek to learn about different populations and community settings. Responders should strive to optimize the exam process for each group. They should not assume that children and caregivers hold certain beliefs or have certain needs and concerns merely because they belong to a specific population or live in a specific setting. (See below to learn about four broad strategies and key actions that can optimize the exam process for specific populations and settings.)

Broad Strategies to Optimize the Exam Process for

Specific Populations and Settings

Strategy 1:   Reach out to and partner with those who serve specific populations.

Strategy 2:   Learn about issues facing specific populations of prepubescent children in the community.

Strategy 3:   Plan across responding entities to meet the needs of specific populations of child victims and remove barriers they face in accessing timely, high-quality examinations.

Strategy 4:   Evaluate the inclusivity and accessibility of forms and informational materials. 



Broad Strategies to Optimize the Exam Process for Specific Populations and Settings

1. Reach out to and partner with those who serve specific populations. Organizations, professionals, and community leaders that serve or represent specific populations may be willing to:

  • provide responders with training and consultation on working with children from populations they serve or represent,
  • give input on the development of response protocols and appropriate services,
  • offer culturally specific support to children and caregivers during the exam process, and
  • be a referral source for children and families (See A3. Coordinated Team Approach ).

Engaging these entities and individuals to improve response to specific populations is not a one-time event in response to individual case needs, but an ongoing, planned effort.

2. Learn about issues facing specific populations of prepubescent children in the community. For example:

  • The prevalence, risk factors, and dynamics of sexual victimization for specific populations of children;
  • Issues, needs, resources, and gaps in services for specific populations of child sexual abuse victims;
  • Geographic factors that impact access to services in the community (e.g., access to and provision of timely care and protection is often challenging in rural and remote regions where community members may be physically isolated from local services by considerable distance and/or difficult terrain);
  • A specific population’s cultural beliefs about sexual abuse and the impact of those beliefs on seeking help to address health, safety, and legal needs of child victims;
  • Oppression, stigma, and other barriers that increase resistance within a specific population or community setting to discussing sexual victimization, disclosing it to authorities, or otherwise seeking help;
  • The historical context in which victimization occurs and impacts a specific population;[15]
  • A population’s practices for healing and seeking justice, and their application to sexual abuse;
  • Aspects of a specific culture that protect children from child sexual abuse and/or can be strengths in helping children in the aftermath of sexual abuse;[16]
  • Coping mechanisms commonly seen in sexual abuse survivors from specific populations;
  • Commonly seen medical issues for specific populations and if/how they can impact medical forensic care;[17]
  • The impact of tribal sovereignty on response to child sexual abuse in American Indian and Alaska Native communities (tribes, as sovereign nations, may have their own laws and regulations; many tribes also have their own health care systems, law enforcement agencies, child protective services/social services, prosecution offices, courts, advocacy programs, and other services to address child sexual abuse);
  • Jurisdictional issues and challenges related to state-tribal relations;[18]
  • Laws and regulations related to the response to sexual abuse in specific institutional settings;[19]
  • Procedures and services to address child sexual abuse on military installations; and
  • Similarities and differences in language and in beliefs and practices related to safety, addressing health concerns, healing, and justice across subgroups of a broad cultural group (e.g., American Indian and Alaska Native, Hispanic, Asian, Muslim, Christian, and Jewish).

3. Plan across responding entities to meet the needs of specific populations of child victims and remove barriers they face in accessing timely, high-quality examinations. For instance, identify/create:

  • Practices to promote access for child victims from specific populations to streamlined, prompt, and culturally and linguistically appropriate medical forensic care, and to encourage reporting of child sexual abuse;
  • Procedures to facilitate outreach to community-based organizations that serve specific populations and invite their participation on the multidisciplinary response team, in the development of response protocols, in team training opportunities, and as resources for children and caregivers as appropriate/applicable in a case;
  • Coordinated response policies that address concurrent jurisdiction in a case (e.g., tribal, state, or federal) or cases that involve institutional settings with their own policies related to sexual abuse response;
  • Policies that facilitate assessment of need for language services in a case, determine specific services necessary, and subsequently ensure services are arranged;
  • Sources of certified interpretation and translation available to responding agencies/facilities, agreements regarding service provision among responding entities and interpreter and translation services, and instruction for responders on utilization of interpreters and translators during the exam process;
  • Resources to accommodate children with disabilities during the exam process, including instructing responders on communicating with individuals using assistive tools and devices as well as interpreters and translators, and guiding responders on modifying exam procedures to accommodate an individual child’s needs;
  • Measures that create an inclusive and welcoming exam process for all children;
  • Policies to address the child’s need for modesty and privacy when providers assisting with communications are present in the exam room;
  • Resources for mental health counseling for specific populations of child sexual abuse victims; and
  • Policies and resources to address the needs facing recently immigrated child sexual abuse victims, including those who are refugees from areas of conflict.[20]

4. Evaluate the inclusivity and accessibility of forms and informational materials.

  • To the extent possible, forms and informational materials should be developed to be inclusive and welcoming to all populations;[21]
  • Translated materials should be available at minimum in languages commonly encountered in the jurisdiction—also be aware of resources for translation into additional languages, especially those emerging in the community (e.g., due to a recent influx of refugees from a particular country); and
  • Written materials should be available in alternative formats such as large font, Braille, plain language, and audio file.


This chapter offered general recommendations for adapting the exam process for each child. Additional considerations are noted throughout the protocol, both broadly and in reference to specific populations and community settings. See www.SAFEta.org for additional resources on working with child sexual abuse victims from specific populations and in specific community settings, as well as on issues of cultural and linguistically appropriate care.



 Table of Contents A3. Coordinated Team Approach

[1] For applicable laws, see www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf (Appendix D of The Joint Commission document).

[2] See Joint Commission’s Standards and Elements of Performance for Patient-Centered Communication (2010) at http://medicine.osu.edu/orgs/ahec/Documents/Post_PatientCenteredCareStandardsEPs_20100609.pdf. Applicable standards include: human resources (HR.01.02.01), provision of care, treatment, and services (PC.02.01.21), record of care, treatment, and services (RC. 02.01.01), and rights and responsibilities of the individual (RI.01.01.01, RI.01.01.03). A federal resource for providing language services across a variety of settings is www.lep.gov. Kidsta.org offers links to resources available through that website, which have particular application for health care settings. The federal government suggests that recipients of federal financial assistance develop a language assistance plan: a process for identifying LEP individuals who need language assistance; information about language assistance measures; training for staff; notice to LEP persons; and monitoring and updating the plan. See Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons, 67 Fed. Reg. 41455 (June 18, 2002).

[3] See Smith and Hope (2015) for a discussion of issues facing victims from the Deaf community to accessing services. Although it is not written specifically about child victims, it can be applied to this population.

[4] To clarify, interpreters convert information from one spoken language into another (or in the case of sign language interpreters, between spoken and sign language), while translators convert written materials from one language to another (Miller, 2012).

[5] Intellectual disabilities is a term used when there are limits to a person’s ability to learn at an expected level and function in daily life (CDC, n.d.). Levels of intellectual disability vary greatly in children. For more information, see www.cdc.gov/ncbddd/actearly/pdf/parents_pdfs/IntellectualDisability.pdf.

[6] Plain language is communication a person can understand the first time they read or hear it—language that is plain to one set of readers may not be plain to others (plainlanguage.gov, n.d.). For tips on developing messages and materials appropriate for targeted audiences, see the CDC (2014b) at www.cdc.gov/healthliteracy/developmaterials/testing-messages-materials.html.

[7] For more information on assistive and augmentative communication, see www.asha.org/public/speech/disorders/AAC/ (American Speech-Language-Hearing Association, n.d.). For further information, see the Assistive Technology Industry Association at www.atia.org/.

[8] If there are concerns about potential damage to an assistive device in the course of forensic evidence collection, consult with appropriate local/regional disability organizations.

[9] The notion that a person is superior based on the ability to hear or to behave in the manner of one who hears (Humphries, 1977).

[10] WCSAP offers a webinar and material (Guy Ortiz, 2008) exploring the concept of cultural competency and service provision strategies to help providers work with survivors of color. It is designed for victim advocacy, but has applicability across disciplines. See www.wcsap.org/culturally-relevant-advocacy-victimssurvivors-color.

[11] Definitions of cultural and linguistic competence have evolved over time (Weaver, 2013). Clinical cultural competence is “the ability of health care professionals to communicate with and effectively provide high quality care to patients from diverse socio-cultural backgrounds” (Betancourt & Green, 2010). Linguistic competence is “the capacity of an organization and its personnel to communicate effectively, and convey information in a manner that is easily understood by diverse groups including persons of limited English proficiency, those who have low literacy skills or are not literate, individuals with disabilities, and those who are Deaf or hard of hearing. Linguistic competency requires organizational and provider capacity to respond effectively to the health and mental health literacy needs of populations served. The organization must have policy, structures, practices, procedures, and dedicated resources to support this capacity” (Goode & Jones, 2009). A more general explanation of cultural competency is ensuring cultural applicability of services and options; and sensitivity to the role of culture in a person’s experience and decision making (adapted from Proffitt, 2010; NSVRC & RSP, 2013). See the National Center for Cultural Competence at http://nccc.georgetown.edu/foundations.html for further information on frameworks, guiding values, and principles for organizations to achieve cultural and linguistic competence. To help ensure cultural competency in the exam process, involved entities are encouraged to consider and evaluate (adapted from NSVRC & RSP, 2013): In routine services, how is the cultural competence of services provided assessed? Are involved agency and team structures, locations, designs, and/or décor representative of the communities that they serve? Are services available in the preferred languages of children and caregivers? Do responders receive training and supervision on cultural competency? Do responders collaborate with partnering organizations that have expertise in working with different cultures? Is there diversity in the staff of the responding entities?

[12] This listing was adapted in part from Day and Pierce-Weeks (2013), IRC (2012), and Weaver (2013).

[13] This awareness enables responders to: (1) not assume someone is male or female; and (2) engage in discussions that includes what name, pronoun, gender identity, and language that people use to describe themselves. It is also important for responders to understand that sexual abuse may be intertwined with the victims’ gender identity—e.g., people may experience violence due to their perceived gender identity. (M. Munson, personal communications, 2015).

[14] If responders do not understand children’s vocabulary, it is possible they might misinterpret their account of what happened. For example, in one case, a young girl was taught by her caregivers to call her vagina her “purse.” When she tried to tell a trusted adult she had been sexually abused, she said, “He touched my purse.” Not being aware of the meaning of the child’s words, the adult initially told her there was nothing wrong with someone touching her purse. Some child sexual abuse victims have considerable shame about or dissociation from their bodies. If it is too difficult to talk about their bodies, consider alternative means of communication (e.g., anatomically detailed dolls the child can use to point to body parts or paper and pen so the child can write or draw).

[15] For example, see the Minnesota American Indian Women’s Resource Center (2009) for a history on victimization and oppression of Native women and girls and its impact on current day commercial sexual exploitation of this population in Minnesota.

[16] For example, in cultures where elders have leadership and mentoring responsibilities, they may play an integral role in promoting safety and wellbeing of children as well as be instrumental in facilitating family healing from sexual abuse.

[17] For example, children may have disabilities that cause physical immobility and affects their ability to get on and off an exam table, among other activities. Prepubescent children may be receiving hormone treatment for pubertal suppression and anticipated subsequent gender transition (see Hewitt et al., 2012; Shumer & Spack, 2013; Spack et al., 2012).

[18] For example, a state school system on reservation lands, which has access to tribal children, may not follow tribal law on mandatory reporting of child abuse.

[19] For example, PREA standards for detention facilities set requirements for sexual abuse prevention, detection, response, and monitoring.

[20] The National Immigrant Women’s Advocacy Project is a source for related information and resources. Also see Dettlaff and Johnson (2011), Dirks-Bihun (2014), and Lin and O’Brien (2013).

[21] The field of universal design provides a framework to create printed materials that are accessible to the widest possible audience of users. See www.universaldesign.com/what-is-ud/. For example, intake form questions that ask about sex and gender should allow a response to be written in or include transgender and intersex options. Questions should appropriately distinguish between sexual orientation (the gender(s) to which one is attracted), gender identity (the internal sense of being female, male, or gender non-conforming), and biological sex. Any questions regarding religious affiliation should be inclusive of the diversity of faith communities in the area, and provide options for no affiliation and for writing in an answer.