Injuries in the genital area tend to heal very quickly; therefore, most children and adolescents who disclose sexual abuse have no physical evidence of the abuse. Behavioral signs may include depression, anxiety, anger, loss of appetite, withdrawal from normal activities, substance abuse, self-mutilation, fear of certain places or people, bed wetting, night sweats, nightmares, thoughts of suicide, sexualized behavior, and use of language that is not age appropriate.

• Bruises or welts on the body or face, particularly when they are in multiple stages of healing, are located in multiple areas of the body, or are in unusual patterns that may be consistent with the object utilized to perpetrate the abuse (ie: belt, extension cord, “fly swatter” impressions). It is also helpful to remember that infants who are too young to “cruise,” rarely bruise. • Burns, including circular burns consistent with cigar or cigarette burns, glove or “sock-like” burns on the extremities, doughnut-shaped burns on the buttocks, or any burns consistent with the object utilized to burn the child (ie: iron). • Fractures, particularly any fracture in children less than 2 years of age, spiral fractures of long bones, and multiple fractures in various stages of healing. • Internal injuries. • Cuts and bruises on the face or in the genital area. • Human bite marks. • Missing patches of head hair.

At The Cottage, our providers follow the nationally recognized, evidence-based guidelines established for the care of abused children and adolescents. According to those guidelines, if there is any suspicion, regardless of whether or not the child or adolescent makes a disclosure or denial, should have a medical-forensic examination performed by an appropriately trained pediatric medical-forensic provider in a child-friendly environment. To ensure the safety, health, and well-being of these children and adolescents, they should all have specialized medical-forensic examinations in the absence of disclosure and even when they deny any history of abuse. Those guidelines also recommend that all “contact children” also have a medical-forensic examination. A “contact child” is any child or adolescent who has also had any type of in-person contact with the alleged perpetrator. To ensure the safety, health, and well-being of these children and adolescents, they should all have specialized medical-forensic examinations in the absence of disclosure and even when they deny any history of abuse. ALL children and adolescents residing in a home or who frequently visits a home where child pornography was discovered/confiscated should be scheduled for a medical-forensic evaluation with a properly trained, pediatric medical-forensic provider. To ensure the safety, health, and well-being of these children and adolescents, they should all have specialized medical-forensic examinations in the absence of disclosure and even when they deny any history of abuse. IMPORTANT NOTES: 1. It is not uncommon for child and adolescent victims to deny suspected child sexual abuse, even when interviewed by highly trained and experienced pediatric forensic interviewers and subsequently have significant genital findings and/or are positive for sexually transmitted infections (STIs) on medical-forensic examination; therefore, ANY and ALL suspected child and adolescent victims of sexual abuse and ALL contact children and adolescents undergo a medical-forensic examination by a properly trained pediatric medical-forensic provider. It is imperative to ensure their health and safety. 2. STI's can be asymptomatic (with no symptoms). Untreated STI's can and do cause serious and long-term complications (even impacting their reproductive health and ability to have children of their own in adulthood); therefore, regardless of how long ago the suspected abuse occurred and how many times the child or adolescent has been seen by their primary care provider, he/she should be scheduled for evaluation with a properly trained and experienced pediatric medical-forensic provider.

Any patient who believes they have been sexually assaulted and have not yet had an examination by a properly trained medical-forensic examiner.

In cases of suspected child or adolescent abuse or neglect, knowing when to seek emergency medical treatment in an emergency department (ED) setting is important. Community-based medical-forensic centers like The Cottage is the ideal and preferred setting for evaluating suspected child and adolescent victims of sexual abuse who are medically stable. Any child or adolescent with acute physical injuries that may require stitches, suspected fractures or dislocations, head injuries, memory loss, reports strangulation within the past 3-4 days, or any other acute, serious, or life-threatening injury or illness should be evaluated and medically cleared and stable prior to being seen by the medical-forensic provider at The Cottage. Once the patient is stable and discharged from the ED or hospital, he/she can be seen at The Cottage for a proper medical-forensic examination.

In cases of suspected child or adolescent sexual abuse, knowing when to seek emergency medical treatment in an emergency department (ED) setting is important. Community-based medical-forensic centers like The Cottage is the ideal and preferred setting for evaluating suspected child victims of sexual abuse who are medically stable. In many situations, a parent or caregiver learns that the abuse has been longstanding (but not occurring in the 3-4 days prior to the disclosure) or may have stopped quite some time prior to the child or adolescent’s disclosure. While proper services for both the patient and family are needed as soon as possible, this type of disclosure is rarely a medical emergency. To protect the patient from unnecessary upset and traumatization, evaluation in an ED for child or adolescent sexual abuse should be reserved only for true emergencies that require immediate medical attention. When no qualified provider is immediately available at The Cottage, urgent evaluation in an ED should be considered when any child or adolescent who has disclosed sexual contact that occurred within the previous 72 hours OR any child or young adolescent who has been observed engaging in sexual contact within the previous 72 hours. Any child or adolescent with acute genital or anal injuries, physical injuries that may require stitches, suspected fractures or dislocations, head injuries, memory loss, reports strangulation within the past 3-4 days, or any other acute, serious, or life-threatening injury or illness should be evaluated and medically cleared and stable prior to being seen by the medical-forensic provider at The Cottage. Once the patient is stable and discharged from the ED or hospital, he/she can be seen at The Cottage for a proper medical-forensic examination.

Community-based medical-forensic centers like The Cottage is the ideal and preferred setting for evaluating medically stable sexual assault patients. To protect the patient from repeat traumatization, evaluation in an emergency department (ED) after a sexual assault should be reserved only for true emergencies that require immediate and emergent medical attention. When no qualified provider is immediately available at The Cottage, urgent evaluation in an ED should be considered if the assault occurred within the past 3-5 days. Any sexual assault victim with physical injuries that may require stitches, suspected fractures or dislocations, head injuries, memory loss, reports strangulation within the past 3-4 days, or any other acute, serious, or life-threatening injury or illness should be evaluated and medically cleared and stable prior to being seen by the medical-forensic provider at The Cottage. Once the patient is stable and discharged from the ED or hospital, he/she can be seen at The Cottage for a proper medical-forensic examination.

Most pediatric and family practice primary care and urgent care offices and clinics are not comfortable with managing cases of suspected child abuse, particularly suspected cases of child or adolescent sexual abuse, and most of those offices do not have the specialized equipment to properly perform and document these examinations. Additionally, many providers in those settings are not trained to provide the sub-specialty care required in these cases. At The Cottage, children receive sub-specialty care in a private, community-based, medical setting by providers who specialize in child abuse, and our patients and their families are provided with the support necessary to help them through the process. Multiple examinations should be avoided; therefore, seeking proper care for the child or adolescent from the appropriate specialist as soon as possible is essential.

Most primary care and urgent care offices and clinics are not comfortable managing sexual assault cases, and most of those offices do not have the specialized equipment to properly perform and document these examinations. Additionally, many providers in these settings are not trained to provide the sub-specialty care required in these cases, even if the patient chooses only to receive medical care without requesting evidence collection. Emergency departments (ED) are very busy, and it is difficult to provide personalized and comprehensive care to sexual assault patients in those environments. Community-based medical-forensic centers like The Cottage is the ideal and preferred setting for evaluating medically stable sexual assault patients. To protect the patient from repeat traumatization, evaluation in an ED after a sexual assault should be reserved only for true emergencies that require immediate and emergent medical attention. When no qualified provider is immediately available at The Cottage, urgent evaluation in an ED should be considered if the assault occurred within the past 3-5 days. Any adult sexual assault victim with physical injuries that may require stitches, suspected fractures or dislocations, head injuries, memory loss, reports strangulation within the past 3-4 days, or any other acute, serious, or life-threatening injury or illness should be evaluated and medically cleared and stable prior to being seen by the medical-forensic provider at The Cottage. Once the patient is stable and discharged from the ED or hospital, he/she can be seen at The Cottage for a proper medical-forensic examination. At The Cottage, our patients receive sub-specialty care in a private, community-based, medical setting by providers who specialize in providing care to sexual assault patients across the lifespan, and our patients are provided with the support necessary to help them through the process.

At the Cottage, we provide initial and follow-up medical-forensic care to child and adolescent victims of all forms of abuse. We also provide initial medical-forensic evaluation and care to adult sexual assault victims.

What we DO for children and adolescents at The Cottage: • We provide crisis intervention. • We provide initial and follow-up care to suspected child and adolescent victims of abuse. • We take a medical history, from the parent or guardian, as well as a history of why your child or adolescent was referred to The Cottage. • We complete physical examinations. • We may use special equipment to better visualize the anal and genital areas. • We may briefly talk with the child or adolescent alone. • We test for sexually transmitted infections and pregnancy, if indicated. • We provide referrals for mental health and other services in the community in which the family resides. • Provide information on the Georgia Crime Victim’s Compensation Program to parents and caregivers, and we assist them with filing for benefits through that program, if necessary. What we DO NOT do for children and adolescents at The Cottage: • We do not perform “internal” or invasive exams of children or young adolescents. • At the present time, we generally do not conduct comprehensive forensic interviews with children; however, we do work closely with a multidisciplinary team to ensure that all children and families receive the services they need.

What we DO for adults at The Cottage: • We provide services to sexual assault patients. • We provide crisis intervention. • We take a medical history and a history of the reported sexual assault. • We complete physical examinations. • We offer evidence collection utilizing evidence collection kits (also often referred to as a "rape kit") to patients whose assault occurred within the past 5 days. • We photograph any injuries. • We utilize special equipment to better visualize the anal and genital areas to help identify and document "micro trauma" to those areas that may not be seen with the naked eye. • We offer and provide initial medical care, including testing for sexually transmitted infections (STIs) and pregnancy, STI prophylactic (preventive) treatment, and emergency contraception (prevents pregnancy). • We provide referrals for follow-up medical care, mental health, and other services in the community where the patient resides. • We provide information on the Georgia Crime Victim’s Compensation Program and assist with filing for benefits through that program, if necessary. What we DO NOT do for adults at The Cottage: • We do not provide care to adult patients without a complaint of sexual assault. • We do not provide follow-up or on-going medical care to any adult patients.

No, sexual assault patients are not required to cooperate with the police in order to receive a medical-forensic examination, and police are not required to “approve” or request such an examination in order for patients to have one. Under Georgia law, sexual assault victims are not required to cooperate with law enforcement to obtain a FREE forensic-medical examination, and law enforcement agencies are required to store any evidence collected during that examination for a minimum of one (1) year. IMPORTANT NOTE: Our staff at The Cottage, however, is mandated by law to report any suspected or actual crimes against any minor under the age of 18. We are also required to report sexual assault, domestic violence, or physical violence to law enforcement, regardless of the age of the victim.

Patients age 13 and older can provide consent for medical-forensic care after an incident of sexual violence. IMPORTANT NOTE: Our staff at The Cottage, however, is mandated by law to report any suspected or actual crimes against any minor under the age of 18 to law enforcement and/or the Department of Family and Children Services (DFCS).

There is no charge to the patient or the family for the initial care of any child, adolescent, or adult with a complaint of sexual abuse at The Cottage. The cost of care for child and adolescent patients evaluated for physical abuse or neglect (without a component of sexual abuse) will be billed to the child’s health insurance plan. If the pediatric patient does not have insurance coverage, we are not set up for reimbursement under their plan, or their plan requires payment of a co-pay and/or deductible, we will assist the family with filing for benefits and reimbursement for charges under the state crime victim’s compensation program. Most children only require one visit with the providers at The Cottage; however, if follow-up visits are required for your child or adolescent, the cost of that care will be billed to the child’s health insurance plan. If the pediatric patient does not have insurance coverage, we are not set up for reimbursement under their plan, or their plan requires payment of a co-pay and/or deductible, we will assist the family with filing for benefits and reimbursement for charges under the state crime victim’s compensation program.

Please refer them to the "Your Visit" and "FAQ" sections our website. Also, encourage them to complete their new patient questionnaires through their online patient portal 24 hours prior to their appointment to reduce the length of that appointment. Parents and patients should receive an invitation to that portal in the email address provided to our staff.

Child and Adolescent Patients: 1. Proof of guardianship such as custody papers (if you are not the child’s parent). 2. Another adult to sit with their child while they speak with the treatment team at The Cottage, if at all possible. ​ 3. The child’s insurance card(s) - ONLY IF the child is covered under a health insurance plan AND the appointment is not for an initial sexual abuse evaluation (ie: the evaluation is for suspected physical abuse or neglect or is a follow-up visit). Adult Patients: A change of clothing if they have not changed clothes since the sexual assault (those clothes worn at the time of the assault will be collected as evidence), if possible. IMPORTANT NOTE: The Cottage does not allow suspected or alleged perpetrators or non-supportive caregivers on the premises, so please ask them to plan accordingly.

Our medical providers will weigh, measure, take vital signs, and perform a complete head-to-toe physical examination on the patient. No part of the physical exam should cause the child or adolescent any pain. The genital exam involves an external look at the child or adolescent’s genital area utilizing a special instrument called a colposcope. This instrument provides good light and magnification to facilitate better visualization of all structures. The colposcope does not touch the patient’s body in any way, nor is it felt by the patient; however, the provider will need to touch the patient’s genital and anal areas to facilitate proper visualization of all external structures. It is important for children, adolescents, and parents to understand that the genital exam is very different and far less invasive than an adult pelvic exam, and it is absolutely in no way comparable to a “pap smear.” Vaginal speculums are not inserted inside children and young adolescents. Patients are never forced, and they are given as much time as necessary to feel comfortable with the exam. If the child or adolescent is very resistant, the exam can be rescheduled for a later date or not done at all. Most children and adolescents are cooperative when they are reassured that the decision to have the exam is ultimately their own. Our patients are always treated with dignity and respect.

No part of the medical-forensic examination should cause the child or adolescent any pain. It is important for children, adolescents, and their parents to understand that the genital exam is very different and far less invasive than an adult pelvic exam, and it is absolutely in no way comparable to a “pap smear.” Vaginal speculums are not inserted inside children and young adolescents. Patients are never forced, and they are given as much time as necessary to feel comfortable with the exam. If the child or adolescent is very resistant, the exam can be rescheduled for a later date or not done at all. Most children and adolescents are cooperative when they are reassured that the decision to have the exam is ultimately their own. Our patients are always treated with dignity and respect.

All of our patients receive trauma-informed, high-quality, evidence-based, patient-centered care in a private, controlled, community-based setting. Their care is provided by a highly trained and experienced medical-forensic provider. Patients presenting to The Cottage for care within 120 hours (5 days) of the assault are offered a medical-forensic examination with evidence collection. Upon arrival, patients are asked to sign consents for the examination and treatment, provide a medical history, and provide a detailed history of the sexual assault. If they are wearing the clothing they wore during the assault, they are asked to provide it as evidence. If they have already changed clothes, the patient may be asked to provide their panties or underwear as evidence. Patients will be asked to change into a gown, and depending upon the history provided, they may also be asked to provide a blood sample. A head-to-toe physical examination will be performed by the medical-forensic provider. The provider may also look at the patient's body with a florescent lamp that allows visualization of evidence that cannot be seen with the naked eye. The medical-forensic provider may take photographs or video to document any bruises, scrapes, cuts, or other potential injuries identified during the physical examination process. Utilizing cotton swabs, the medicall-forensic provider may collect possible evidence from different parts of the body, inside the mouth, and under the fingernails. Any debris identified on the patient's skin may also be collected. The provider will also examine the genital and anal areas for any injuries, including “micro injuries,” and collect possible evidence utilizing a cotton swab. After the examination, our medical-forensic provider will discuss with the patient a plan of care that may include the need for additional medical care, such as lab testing for sexually transmitted infections (STI) and pregnancy, x-rays, medications, immunizations, and/or follow-up examinations and where and how to obtain that care. Our provider will also discuss what other steps need to be taken and place referrals for any additional services the patient may need to facilitate proper healing after the sexual assault. IMPORTANT NOTE: Patients always have the right to REFUSE any part(s) of the examination they so choose.

Not necessarily. Most children and adolescents have no physical injuries in their genital and/or anal area following abuse. This does not mean or “prove” that no sexual abuse or contact occurred. The medical exam may, however, help to corroborate the patient’s disclosures or support any suspicions or allegations.

Not necessarily. Many adults have no physical injuries in their genital and/or anal area after a sexual assault; however, this does not mean or “prove” the patient was not sexually assaulted. The prescence of injury also does not "prove" the patient was sexually assaulted. The medical-forensic exam may, however, provide evidence to corroborate the allegations. Also, injuries in the genital and anal area tend to heal very quickly; therefore, it is important that victims seek care as soon as possible after a sexual assault.

Financial resources are available to crime victims under the Georgia Crime Victims Compensation Program. Find information about the program by visiting the following website: http://crimevictimscomp.ga.gov/for-victims/ Our staff at The Cottage are available to assist patients and their families with applying and filing for any benefits through the program.