B1. Consent for Care

These recommendations are for health care providers.

Be aware of which health care procedures require consent during the exam process. Consent sought by health care providers related to the examination generally should cover the following, as applicable/indicated in a specific case:

Initial health care assessment (see B3. Entry into the Health Care System);
The medical forensic examination;
Testing and treatment (e.g., STDs, including HIV, and toxicology);
>Forensic sample collection;
Photo-documentation of the exam findings; and
Permission to contact the child and caregiver for medical follow-up purposes.

Identify who needs to provide consent for care for prepubescent children.[1] Prepubescent children are generally below the age to consent to their own care in a jurisdiction.[2] Thus, health care providers need to identify the person(s) responsible for providing permission for the child’s care (e.g., the parent/guardian). They also need to know the mechanisms in place at their facility to obtain consent for care if abuse or neglect of the child by the parent/guardian is suspected or if a parent/guardian refuses to consent or is absent. (In such instances, child protective services and/or law enforcement should be consulted immediately, as a court order may be needed to take the child into protective custody. Pediatric examiners are encouraged to discuss this potential situation in advance with law enforcement and/or child protective service agency representatives and facility legal counsel to determine specific procedures to follow) Be aware that consent may be withdrawn at any time during the exam process, even if consent forms have been signed.[3]

In addition to seeking consent, seek prepubescent children’s assent for care throughout the exam process. (See General Consent/Assent Guidelines below) Assent is the expressed willingness of an individual to participate in an activity. Assent should be sought from children who are by jurisdictional definition too young to grant informed consent for care, but old enough and/or developmentally able to understand and agree to participate in that care (IRC, 2012). Note that assent has particular relevance with sexually abused children—when their wishes are respected in health care, it can help return control that was taken away from them when they were abused or perhaps give them control for the first time (adapted from Day & Pierce-Weeks, 2013; WHO, 2003).

Make sure that consent and assent are informed. To obtain permission to proceed with an exam procedure, health care providers should explain its full nature to the child and parent/guardian (e.g., what it entails, the rationale, possible side effects, and the potential impact of declining). Inform them that the examination is much like an annual well-check examination recommended for children (and IS NOT an invasive procedure with a speculum as a caregiver might expect). They should be informed that information and forensic evidence obtained during the examination will be released to investigative agencies. They should also be told whether others can access this information, as prescribed by jurisdictional policies (e.g., data, minus patient identity, may be collected for health or forensic purposes by qualified persons with a valid educational or scientific interest for demographic and/or epidemiologic studies). Children and parents/guardians should be told their options and encouraged to ask questions about the process, and to apprise health care providers if they wish to decline a particular exam procedure. Providers should refrain from judgment or coercive practices in seeking consent; it is contrary to ethical and professional practices to influence their decisions.

Child’s Parent/Guardian

*General Consent/Assent Guidelines*
Child’s Age	Child (consider her/his development level and linguistic capacity and preferences when planning if/how to seek assent)	Child’s Parent / Guardian	If No Parent/Guardian or Parent/Guardian Is Not Acting in Child’s Best Interest	Means
0-5	Generally not capable of informed assent (but consider each child’s developmental capacity)	Informed consent	Follow jurisdictional/facility policies for seeking consent in these instances	Written consent
6-11	Generally capable of informed assent (but consider each child’s developmental capacity)	Informed consent	Follow jurisdictional/facility policies for seeking consent in these instances	Oral assent, written consent

In the case where the child and/or parent/guardian declines a component of the examination, the health care providers should assess if anything can be done to make the procedure acceptable. For example, if the child initially declines photo-documentation, the health care provider might ask if it would be acceptable to take certain photographs, but not others (anogenital images may be the specific problem and the child and parent/guardian may agree to other images being photographed). Ensuring a child-focused, victim-centered, and trauma-informed approach from the start can heighten children’s comfort and trust in health care providers, which might increase their willingness to participate in the process. (See A1. Principles of Care and A2. Adapting Care for Each Child)

Follow facility and jurisdictional policies related to obtaining verbal and written consent. In addition to verbally providing information and seeking assent and consent from children and parents/guardians, written consent from a parent/guardian of the child is necessary to carry out specific exam procedures (unless the child has been placed in protective custody). Health care providers should know facility and jurisdictional policies for when written consent is necessary and the methods to obtain it. Ensure all signatures and dates needed are obtained on written consent forms. Providers also need to be aware of verbal and nonverbal cues from children and guardians and adjust methods of seeking assent and consent to meet their needs. ( See A2. Adapting Care for Each Child) The consent process may be enhanced if health care providers are instructed on logistically how to seek verbal consent and assent in these cases, in a way that is consistent across cases, to help facilitate the exam process. Consent and assent should be documented in the medical record, as well as the reasons for declining consent and assent.[5] (See B4. Written Documentation)

Checklists, forms, patient brochures, and videos about the exam process can help facilitate obtaining consent and assent. Written health care consent forms developed for the purpose of the examination should be reviewed and approved by facility administration and the legal department. Documentation on consent becomes part of the child’s medical record. Standardized consent forms are typically included in the jurisdictional forensic evidence collection kit, which may or may not cover all aspects of care.

Tailor the process of seeking assent and consent so it is developmentally appropriate for the child, and linguistically appropriate for children and parents/guardians. (See A2. Adapting Care for Each Child) Information provided should be complete, clear, and concise, and accommodate the family’s communication skill level/modality and language. Note that some children and parents/guardians may require the use of language interpreters for verbal consent and sight translation of written documents and forms into other languages.[6] Children and parents/guardians with cognitive disabilities may also require accommodations to proceed with this process.

Seeking assent often requires considerable time and patience on the part of examiners. For example, it may take considerable effort to help children become comfortable enough to express themselves and feel safe to proceed with a particular procedure. Victim advocates may be useful in providing children and caregivers with support. A hospital-based child life specialist or social worker, where available, may also assist in describing needed medical procedures to the children and caregivers.

Do not proceed with an examination without the assent/cooperation of the child, even if the child’s parent/guardian gives consent (with exceptions in instances of serious medical injury, pain, or trauma to be evaluated/treated). For example, do not restrain or otherwise force children to comply with any part of the examination, including sedation against their will.[7] If a child is not tolerating the examination, consider whether an opportunity exists for re-examination in the near future.

Consider how to approach different consent scenarios. If the health care facility does not have policies for an individual patient situation, the child sexual abuse multidisciplinary response team might be a resource for feedback on appropriate interventions (Constantino et al., 2014). If a child presents to a health care facility and no related policy is in place to address a specific situation, a discussion and decision with involved health care providers and the child’s parent/guardian should occur immediately and be documented (Constantino et al., 2014).

In the case of a prepubescent child who is unconscious and not expected to quickly regain consciousness and a suspicion of acute sexual abuse exists, or the timing of the abuse is unknown,[8] medical forensic care generally should not be delayed (although such a decision should be made on a case-by-case basis). Not only is it critical to promptly determine if the child has serious injuries that require immediate care and provide any necessary treatment, a limited window of time exists to collect forensic samples from this victim population. (See A5d. Timing of Evidence Collection) Also, forensic evidence may be lost in the health care setting if not promptly collected. Pediatric examiners should collaborate with the hospital emergency department and trauma teams to allow medical forensic care to proceed concurrent with emergency procedures. As discussed in B7. Examination, the medical forensic examination for prepubescent children is noninvasive (e.g., it does not include speculum or swab penetration into the vaginal canal). Medical forensic care should include an assessment of the anogenital area for acute injury, bleeding, or foreign material prior to surgical preparation or treatment activities, such as bladder catheterization, which may interfere with recovering biological evidence (Pierce-Weeks & Campbell, 2008). Optimally, informed consent for medical forensic care for an unconscious child should be sought from the child’s parent/guardian as per facility policies. Procedures for proceeding with a medical forensic examination should also be in place in situations where suspicion exists that the parent/guardian is the perpetrator, an ally to the perpetrator, or otherwise abusive to the child, OR the parent/guardian does not consent or is absent.

Coordinate with other responding agencies/facilities in the jurisdiction in efforts to seek consent. All responders should be clear regarding which involved professional has the knowledge to provide children and parents/guardians with information on a particular procedure or intervention. For example, law enforcement and child protective service representatives or victim advocates should not seek consent for medical forensic care. However, they may need to seek consent for activities related to the exam process, such as arranging transportation for the child and caregiver to the health care facility. Health care providers should not seek consent for children to participate in forensic interviews. Law enforcement and child protective service representatives and health care providers should not seek consent for provision of victim services to children or caregivers. While initial responders might offer an overview of various providers’ roles in the exam process—and even introduce children and caregivers to other responders—they should not seek consent for interventions provided by other responders.

See www.SAFEta.org for sample consent forms and patient materials that help children and caregivers with decision making in these cases, and further tips for health care providers on seeking consent and assent. Also contact staff at Kidsta.org to discuss specific scenarios where a child and/or parent/guardian are hesitant to agree to or decline a procedure, and health care responder’s actions in such situations.

Table of Contents

B2. Initial Response

[1] This and the next paragraph were drawn primarily from Day and Pierce-Weeks (2013).

[2] Most jurisdictions allow minors who are age 12 years and above some consent rights related to access to health care services and confidentiality of care (for examples, see Guttmacher Institute (2015)). However, in most jurisdictions, prepubescent children do not have consent rights. Health care providers should be familiar with the applicable laws of their jurisdiction.

[3] Note that, as discussed in A5a. Reporting and A5b. Confidentiality and Release of Information, consent is not necessary to mandatorily report suspected prepubescent child sexual abuse (a HIPAA exception), release the medical forensic report or the child’s medical record to investigative agencies, or share information among investigative agencies or the multidisciplinary response team, if permitted by jurisdictional law.

[4] The chart was adapted from IRC (2012).

[5] As noted in A5b. Confidentiality and Release of Information, release of the child’s medical records for an investigation of child sexual abuse should not be delayed for parental signatures.

[6] See the Joint Commission’s New and Revised Standards and EPs for Patient-Centered Communication, Accreditation Program: Hospital, RI, 01.01.03, effective January 1, 2011.

[7] Sedation or anesthesia should only be used in cases where an acute medical need exists for an intra-vaginal exam or intra-anal exam. This may include cases of internal injury, bleeding from the vaginal area, tears that need repair, or the presence of a mass or foreign objects. If sedation or anesthesia must be used, it should be with the child’s assent, whenever possible, and in consultation with the appropriate pediatric specialists. (See B7. Examination.).

[8] Circumstances of unconsciousness that may lead to a suspicion of child sexual abuse include but are not limited to unconsciousness from (1) abusive head trauma, with associated subdural, subarachnoid, and retinal hemorrhages; diffuse axonal injury; or acute respiratory compromise or arrest with/without associated cutaneous injuries and skull fractures (Hymel & Deye, 2011); (2) traumatic internal injury (e.g., abdominal injury) or external injury (e.g., vaginal or anal laceration) associated with blood loss; (3) drug-induced unconsciousness; (4) metabolic causes associated with neglect, torture of starvation, malnutrition, and/or exposure extreme heat or cold; or (5) caregiver history that is inconsistent with the clinical presentation of injury, or radiologic or laboratory findings on the child (Hymel & Deye, 2011). For more information and research on pediatric abusive head trauma, see the CDC (2015d) at www.cdc.gov/violenceprevention/pdf/PedHeadTrauma-a.pdf .