Language needs for limited English proficient patients, Deaf and hard-of-hearing individuals, and those with sensory or communication disabilities. • Ethnic and cultural beliefs and practices. • Religious and spiritual beliefs and practices. • Economic status, including homelessness. • Immigration and refugee status. • Sexual orientation. • Military status. • History of previous victimization. • Past experience with the criminal justice system. • Whether the assault involved drugs and/or alcohol. • Prior relationship with the suspect, if any. • Whether they were assaulted by an assailant who was in an authority position over them. • Whether the assault was part of a broader continuum of violence and/or oppression (e.g., intimate partner and family violence, gang violence, hate crimes, war crimes, commercial sexual exploitation, sex and/or labor trafficking). • Where the assault occurred. • Whether they sustained physical injuries from the assault and the severity of the injuries. • Whether they were engaged in illegal activities at the time of the assault (e.g., voluntary use of illegal drugs or underage drinking) or have outstanding criminal charges. • Whether they were involved in activities prior to the assault that traditionally generate victim blaming or self-blaming (e.g., drinking alcohol prior to the assault or agreeing to go to the assailant’s home). • Whether birth control was used during the assault (e.g., victims may already have been on a form of birth control or the assailant may have used a condom). • Capacity to cope with trauma and the level of support available from families and friends. • The importance they place on the needs of their extended families and friends in the aftermath of the assault. • Whether they have dependents who require care during the exam, were traumatized by the assault, or who may be affected by decisions patients make during the exam process. • Community/cultural attitudes about sexual assault, its victims, and offenders. • Frequency of sexual assault and other violence in the community and historical responsiveness of the local justice system, health care systems, and community service agencies. Clearly, the level of trauma experienced by patients can also influence their initial reactions to an assault and to post-assault needs. While some may suffer physical injuries, contract an STI, or become pregnant as a result of an assault, many others do not. The experience of psychological trauma will be unique to each patient and may be more difficult to recognize than physical trauma. People have their own method of coping with sudden stress. When severely traumatized, they can appear to be calm, indifferent, submissive, jocular, angry, emotionally distraught, or even uncooperative or hostile towards those who are trying to help.38 38 Paragraph adapted from Iowa’s Sexual Assault: A Protocol for Forensic and Medical Examination, 1998, pp. 1–4. 31 Examiners should ensure they do not make credibility determinations based on myths or misconceptions about victim behavior. In addition, patients’ fears and concerns can affect their initial reactions to the assault, their post-assault needs, and decisions before, during, and after the exam process. For example, female and transgender patients may be worried about getting pregnant. If they are already pregnant or have just given birth, they may be concerned about how the assault will affect their children. Patients may be concerned about being infected with HIV or another STI. They may not want anyone to know about the assault, or may be afraid that family members and friends will reject or blame them. They may fear bringing shame to their families or be concerned that family members will seek revenge against the assailant. They may fear perceived consequences of reporting to law enforcement. They may be concerned how their cultural background could affect the way they are treated by responders. They may wonder if the assailant will harm or harass them or their loved ones if they tell anyone about the assault. They may worry about losing their home, children, ability to remain in the United States, job, and other sources of income as a result of disclosure, particularly if an intimate partner assaulted them.39 They may be concerned about costs related to the exam and subsequent care of injuries.40 It is important to avoid making assumptions about patients, offenders, and the assault itself. Forms used during the exam process and discussions with patients should be framed in a way that does not assume they are of a specific background or gender identity and gender expression. Always ask questions and actively look and listen to understand patients’ circumstances and tailor the exam process to address their needs and concerns. Whatever the response, it should be respectful to patients and adhere to jurisdictional policies. Recognize that patients control the extent of personal information they share. While it is useful for responders to get a full picture of patients’ circumstances, it is up to patients to decide whether and to what extent to share personal information. During the exam process, responders may ask patients to divulge some data, such as age or whether they think the assault was alcohol- or drug-facilitated. Some information, such as language needs, may be obvious. There is no reason for responders to question patients about certain data, such