Examination of the Sexual Assault Victim

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Chapter 58

Examination of the Sexual Assault Victim

The majority of sexually assaulted individuals never report the crime to anyone, and only one third of sexual assaults are reported to law enforcement. In many cases, after contact with law enforcement, sexual assault victims are taken to the emergency department (ED) for evaluation, examination, and treatment. Sexual assault victims may also go to the ED without prior contact with law enforcement. In 2009, sexually assaulted patients accounted for approximately one tenth of all assault-related visits to the ED by female patients.1

Some sexual assault victims will cooperate with police investigations, but others will not. Federal legislation guarantees all victims the right to a forensic examination and treatment of sexual assault regardless of their cooperation with legal investigation or their desire to initially pursue prosecution.2 Some states require medical personnel treating sexual assault victims to report the assault to local law enforcement, whereas others forbid such reporting without patient consent. Clinicians must know their own state laws regarding such reports.

Definitions

Sexual assault refers to any sexual contact between one person and another without appropriate legal consent.3 Physical force may be used to overcome the victim’s lack of consent, but this is not mandatory to prove assault. Coercion into sexual contact by intimidation, threats, or fear also defines sexual assault. State laws differ slightly on the definition of exact acts that constitute sexual contact and on which populations are unable to give legal consent. In general, persons under the influence of drugs or alcohol, minors, and those who are mentally incapacitated are considered unable to give consent for sexual contact.

Clinicians who treat sexual assault victims have a professional, ethical, and moral responsibility to provide the best medical and psychological care possible. At the same time, they must collect and preserve the proper medicolegal evidence that is unique to the evaluation of sexual assault cases.

Many hospitals and jurisdictions affiliate with designated sexual assault examination teams to provide specialized evaluation and treatment of victims. These sexual assault response teams (SARTs) provide clear advantages outlined near the end of the chapter. However, victims may be brought to an ED that does not routinely provide specialized care for sexual assault. This chapter is designed to aid clinicians in such a general care location. Prepared emergency personnel can help attenuate the psychological and physical impact of sexual assault. Through proper care of the victim and careful acquisition of evidence, ED staff can help the victim recover from the assault and aid society in improving the prosecution and conviction of sexual predators.

Evaluation and Treatment of Patients Suffering From Sexual Assault

Preparation

Most often local jurisdictions or hospitals provide clinicians with detailed forms and instructions for examination and documentation of sexual assault. This chapter is meant to supplement such instructions and forms. Clinicians should be familiar with local documents before performing a sexual assault examination. Careful step-by-step planning and the use of written protocols ensure the best care for victims and aids in the prosecution and conviction of assailants.

ED personnel must secure patient privacy and designate a separate area for the care of sexually assaulted patients. If medically and logistically possible, interviews should be conducted in a private room separate from the examination room. EDs often have such an area, frequently called the “grieving room” or the “family room.” Law enforcement or other governmental agencies may provide examination kits for the collection of forensic evidence from victims (Fig. 58-1). These kits should be available in the ED and the staff should be familiar with them. If such kits are not provided by local sources, hospital staff may need to assemble their own kits from material found in most EDs. Alternatively, private companies assemble and sell such kits (www.lynnpeavey.com or The Lynn Peavey Company, PO Box 14100, Lenexa, KS 66285-4100). Prepared kits save a tremendous amount of nursing and clinician time when a victim comes to the ED. A checklist of local requirements for sexual assault examination should be included in the kits and serves as a reminder for all the medicolegal procedures to be completed.

Although this chapter is devoted primarily to the evaluation of adult female sexual assault victims, guidelines for the evaluation of adult male sexual assault victims, female child victims, male child victims, and accused assailants are provided in separate sections of this chapter. The same examiners designated to perform adult female examinations may easily perform male victim and assailant examinations; however, examination of a child sexual assault victim often requires considerable expertise and training. When possible, medical staff with extra training in the examination of child sexual assault victims should perform these examinations. If this is not possible, the section “Child Sexual Assault Examinations” should provide emergency medical personnel with a framework to perform an initial examination.

Consent

Consent for the evaluation and treatment of a sexual assault victim is mandatory. The victim has undergone an experience in which her right to grant or deny consent was taken from her, and obtaining consent for medical treatment and gathering evidence has important psychological and legal implications. The victim has the right to decline medicolegal examination and even medical treatment. Before beginning evaluation and treatment, obtain witnessed, written, informed consent. If no local forensic examination forms are available, use the standard ED “consent to treat” forms, but ensure that the patient is well informed and gives verbal consent to each step of the examination. Although a few states mandate that medical personnel report sexual assaults to law enforcement, victims may choose to not discuss the event with police. If the victim cannot give consent for a forensic examination because of a reversible process (e.g., intoxication, an acute psychological reaction), wait several hours for the victim’s mental status to improve to a reasonable level before consent is obtained. When victims cannot give consent because of minor status or a developmental disability, the person authorized to give medical consent for the patient may give consent for the examination unless that person is a suspect in the assault. Many states allow an adolescent victim of a certain age (e.g., >12 to 14 years old) to consent to an examination for conditions related to sexually transmitted diseases (STDs), sexual assault, and pregnancy. State laws also differ in examiners’ requirements to make an attempt to contact the legal guardian (unless the guardian is a suspected perpetrator). Clearly, emergency personnel must be informed regarding their local laws concerning these requirements. In the rare case that a victim cannot give consent as a result of a potentially irreversible medical condition, such as severe head trauma and coma, seek the advice of institutional legal council before proceeding with a forensic examination. In some cases, the next of kin may provide the needed consent, whereas in other cases, it may be necessary to obtain a court order to proceed.

History

The history of the event should include only the elements necessary to complete the required forms, to perform a focused physical examination, and to collect evidence. Questions beyond this, such as the details leading up to the assault, should be left to police investigators. Avoid the urge to “help” the alleged victim by unduly embellishing or detailing uncorroborated or nonmedical information supplied during the examination. Limiting the history not only shortens the evaluation in the ED but also helps prevent discrepancies between the ED history and the official police investigation report, which could weaken the victim’s case in court. Document the pertinent medical history, including the last menstrual period, current contraception, recent anal-genital injuries or surgeries, and preexisting injuries.

The history of the event required by legal forms or protocol usually includes the time, date, and place of the alleged assault and a description of the use of force, threats of force, and the type of assault. Elements of force may include the type of violence used (e.g., grabbing, hitting, kicking, strangling, weapon use), threats of violence, the use of restraints, the number of assailants, the use of alcohol or drugs (forcibly or willingly) by the victim, and any loss of consciousness experienced by the victim. Sexually assaultive acts may include fondling (of breasts, genitalia, or both); vaginal, oral, or anal penetration or attempted penetration (with fingers, penis, or other objects); ejaculation on or in the body; and the use of a condom. Use of physical force or violence is partly a police matter, but from a medical standpoint, it is desirable to correlate positive findings on the physical examination (e.g., abrasions, ecchymoses, and scratches) with a description of any force, restraint, or violence.

Document the postassault activity commonly requested on forms, including douching, bathing, urinating, defecating, gargling, and brushing teeth. These activities can alter the recovery of seminal specimens and other sexual assault evidence. However, hygiene activities should not deter the clinician from the collection of evidence since DNA has been recovered from the victim’s skin after multiple showers. In addition, question victims about potential injuries from any body trauma before the assault.

Elements of the victim’s history should help in deciding which potential samples to collect. For example, sperm may be recovered from the cervix for up to 12 days after intercourse and from the vagina for up to 5 days (Table 58-1).4 If the victim had voluntary intercourse 48 hours before the examination and was sexually assaulted 3 hours before the examination, obtain samples from both the vagina and the cervix and keep the two types of specimens separate. Taking a careful history makes it possible to perform an appropriate examination given these two separate events. In general, cervical swabs should be collected in addition to the usual vaginal swabs if the time between assault and examination is longer than 48 hours or if intercourse with a different person took place within a few days of the assault. Some experts advocate cervical samples in all cases that will involve speculum examination because of greater forensic yield.

TABLE 58-1

Maximal Reported Time Intervals for Sperm Recovery

BODY CAVITY MOTILE SPERM NONMOTILE SPERM
Vagina 6-28 hr 14 hr-10 days
Cervix 3-7 days 7.5-19 days
Mouth 2-31 hr
Rectum 4-113 hr
Anus 2-44 hr

From Marx J, ed. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 6th ed. Philadelphia: Elsevier; 2006.

Obtain a gynecologic history in preparation for documentation of injuries and treatment plans. From a medicolegal standpoint, question victims about any recent gynecologic surgical procedures or unintentional genital trauma that might alter the expected normal genital appearance. The history should also include the use of any method of birth control before the attack (with information regarding any missed birth control pills), last normal menstrual period, last voluntary intercourse, gravidity and parity, and recent STDs. As with all assaulted patients, the medical history should include current medications, tetanus immunization status, and allergies.

While taking the history, observe the patient’s ability to understand and respond appropriately to questions. Victims of sexual assault may not possess the capacity to consent to intercourse because of a developmental disability, young age, or intoxication with drugs or alcohol. Consider obtaining blood, urine, or both and testing for drugs or alcohol when the history suggests lapses of (or impaired) consciousness. Victims who lack consenting capacity because of a developmental disability may have sufficient prior documentation of the condition. In the rare instance in which an examiner suspects a previously undocumented developmental disability, formal examination of the patient’s mental capacity can be performed at a later time by request of the district attorney.

Physical Examination

Physical examination of a sexual assault victim differs from most other ED examinations in that examiners are not only caring for a patient’s physical and mental well-being but also investigating a crime scene and collecting specific evidence. Explain every step of the examination to the victim. Remind the victim to communicate any discomfort or questions during the examination and to ask for a break from the examination if needed. In addition, remind the victim of her right to decline any portion of the examination and the ability to stop at any point. Each victim should have the opportunity to have a family member, friend, victim advocate, or any combination of such individuals in the room during all parts of the examination.

General Body Examination

After the patient disrobes and is placed in a gown, examine her body for signs of trauma and foreign material. Uncover one part of the body at a time to examine and then carefully re-cover it. This allows the victim to retain some modesty during the examination. Important areas for evaluation are the back, thighs, breasts, wrists, and ankles (particularly if restraints were used). Even in the absence of ecchymosis, note tender areas during the examination. Evidence from the physical surroundings of the assault can occasionally be found in the hair or on the skin. Retain such material as evidence. Document areas of trauma and evaluate further (e.g., with radiographs) as indicated by the type and extent of injury. Approximately 10% to 67% of sexual assault victims display bodily injuries.3 Document these injuries because they correlate significantly with successful prosecution of perpetrators.5 Bodily evidence may range from abrasions to major blunt and penetrating trauma. If the victim has not bathed, bodily evidence in the form of dried semen stains may be visible on the hair or the skin of the victim. In a darkened room, dried semen (and, unfortunately, many other substances) on skin may fluoresce under examination with shortwave light, such as that produced by a Wood lamp or an alternative light source, but may also be noticed equally well by its reflective appearance under regular room lighting.6,7 Use moistened swabs to collect potential dried secretions; then air-dry them thoroughly and preserve as evidence. Fragments of the assailant’s skin, blood, facial hair, or other foreign material from the assault site may be trapped beneath a victim’s fingernails. Obtain fingernail scrapings by cleaning under a victim’s nails with a toothpick or small swab or by cutting the nails closely over a clean piece of paper. Fold the toothpick and debris into the paper, place it in an envelope, and package it with the other specimens.

Imaging

Photographs can be a valuable addition to the documentation of bodily injury. Medical institutions may employ professional-quality photographic teams; others must rely on law enforcement for photo documentation. Most institutions require patient consent for photographs taken by hospital personnel. Optimally, institutions should have a prearranged plan to handle film or digital media according to a written “chain of custody.” Alternatively, self-developing film (Polaroid) or instant digital prints that can be permanently labeled (e.g., subject, date, details of the pictured injury) may be used but will provide inferior resolution in most cases. The photographs should be labeled immediately and may be added to the legal evidence. In some jurisdictions, photographs of physical injuries will be taken and retained by an accompanying law officer. These photographs may serve as evidence or may simply refresh the examiner’s memory at the time of the trial.

Oral Evaluation

If indicated by the history, inspect the oral cavity closely for signs of trauma and collect evidence if indicated. Mouth injuries from forced oral copulation include lacerations of the labial or lingual frenulum, mucosal lacerations, and abrasions. Injury to the lips is often produced by the victim’s own teeth as her lips are forced inward by forced oral penetration with the perpetrator’s penis. Potential injuries to the posterior pharyngeal wall and soft palate include petechiae, contusions, and lacerations (Fig. 58-2). Document these injuries at the initial examination because mucosal injuries heal quickly and may not be present hours or days later. Collect potential evidence with swabs rubbed between the teeth and the buccal mucosa on both the upper and lower gingival surfaces bilaterally. Spermatozoa have been identified in oral smears for hours after the attack despite brushing the teeth, using mouthwash, or drinking various fluids and may provide valuable evidence up to 12 hours after examination.8,9 Collect any foreign material (e.g., hair) to include as potential evidence. During the oral inspection, local law enforcement may request that examiners collect buccal cell swabs to provide the crime laboratory with a sample for victim DNA reference.

Pubic Hair Samples

If local crime laboratories request pubic hair samples, proceed with the following protocol. Before the pelvic examination, comb the victim’s pubic hair for foreign material (particularly pubic hair belonging to the assailant). Place clean paper below the victim’s buttocks with the victim in the lithotomy position and comb the pubic hair onto the paper. Fold these hairs and the comb into the paper and place them directly in a large paper envelope to be given to law enforcement. Foreign pubic hairs can often provide enough cellular DNA material from the root to enable the crime laboratory to perform DNA analysis. In addition, specialized laboratories possess the capability of performing mitochondrial DNA analysis from the hair shaft in many cases.

Significant hair transfer occurs in less than 5% of assaults.10 For the small minority of cases in which foreign suspect hairs must be compared with the victim’s hair, a sample pulled from the victim may be desired. Although pulling the patient’s hair from the roots may provide the best sample, this collection method is painful, considered insensitive, and not recommended by these authors during the initial evaluation. These hairs will rarely be needed because the vast majority of cases are never adjudicated and those that are rarely concern this type of evidence. A victim can provide the hairs at a later time, if needed, and frequently the victim is willing to pluck the hairs herself at that time.

Genital examination of a sexual assault victim differs considerably from most ED pelvic examinations. First, perform a careful evaluation of the vulva and vaginal introitus for signs of trauma. The techniques of separation and traction move the tissues most likely to suffer injury into view. In performing separation, examiners use both hands to separate the labia laterally in each direction and inspect the posterior fourchette and vaginal introitus. Similarly, in performing traction, examiners use both hands to hold each labium majus and apply gentle inferior labial traction (i.e., toward the examiner); this gives a much-improved view of the hymen, especially in prepubertal females (Fig. 58-3). If the examiner fails to perform these maneuvers, traumatic genital injuries may be missed.

Familiarity with female (Fig. 58-4) and male (Fig. 58-5) genital anatomy, including all terms, is important for accurate descriptions. Although most novice examiners concern themselves with detecting injuries to the hymen, the majority of sexual assault–related vaginal injuries occur to the posterior fourchette (Fig. 58-6).11 In fact, hymenal injuries are rare in sexually active adult women and are more commonly observed in sexually inexperienced adolescents12,13 (Fig. 58-7). More uncommon injuries to the vaginal walls and cervix may be discovered during the speculum examination. Reported rates of genital injury in forensically examined victims range from 6% to 20% without colposcopy to 53% to 87% with colposcopy.1113 Most importantly, examiners must be cognizant of the fact that completely normal findings on genital examination remain consistent with forced sexual assault. In fact, a study of more than 1000 sexual assault victims found that almost half of all victims with forensic evidence positive for sperm had no genital injury.14

image

Figure 58-4 Female anatomy.

Colposcopy

Teixeira first described the use of colposcopy for documentation of sexual assault in 1981.15 Although it is not readily available nor a standard of care in most EDs, the use of colposcopy has revolutionized the documentation of injury. The colposcope provides magnification, a bright light source, and usually permanent documentation of injuries in the form of still images or video (mainly in digital format but occasionally traditional film). In one small study the colposcope increased the rate of detection of genital injury from 6% to 53%.16 Colposcopes with photo or video attachments provide excellent photographic documentation for the court and allow review by expert practitioners for court testimony without subjecting the victim to reexamination (Fig. 58-8). Experienced sexual assault examiner programs are increasingly using high-quality digital single-lens reflex cameras mounted on a tripod to obtain excellent images that are indistinguishable from those obtained with colposcopy. ED practitioners may have access to such equipment. Colposcopically visible injuries have also been described in adolescent women after the first consensual intercourse; hence, genital injury does not always correlate with nonconsensual vaginal penetration.17 Conversely, totally normal findings on genital examination by colposcopy are often found after sexual assault. Even in sexually inexperienced adolescents, forced penetration can occur without leaving discernible genital injury.17 Although previous sexual experience by the victim decreases the likelihood of finding genital injury, experts cannot fully explain the reasons why some rape victims sustain measurable genital injury whereas others do not.

Forensic Evidence Collection

Protocols for collection of evidence vary by legal jurisdiction. Many sexual assault evaluation centers have abandoned the cumbersome kits used in the past and substituted simple collection methods that concentrate on important and usable legal evidence. The following discussion draws from the model protocol suggested by the state of California and the American College of Emergency Physicians manual.3

Obtain standard specimens during inspection of the external genitalia, rectum, vagina, and cervix. Lubricate the speculum with warm water rather than other lubricants because of the potential spermicidal activity of lubricants. However, if lubricants are inadvertently used, the potential for corruption of DNA evidence should be negligible.18 Generally, the specimens collected will be determined by victim’s history and local protocol, but they may include any of the items listed in Box 58-1 and shown in Figure 58-9. Some protocols recommend that examiners make a wet mount of one swab from the vaginal pool and look at it under the microscope for the presence of motile sperm. Because of rapid cell death, studies have shown a negligible chance of finding motile sperm from a vaginal wet mount more than 8 hours after intercourse.19 Furthermore, in complying with the Clinical Laboratory Improvement Amendments of 1988, ED practitioners in the United States rarely have sufficient access or experience with microscopy to make this step a routine recommendation. Several swabs from the vaginal pool (including the one used to make the wet mount, if done) and the external genitalia should be obtained and then applied over clean slides for a dry mount. These slides should be allowed to air-dry and then labeled; all swabs and slides should be packaged in paper envelopes for the local crime laboratory. Some EDs maintain specific equipment (i.e., a Dry Box) to aid in the drying of specimens; in others, the swabs and slides must be left out until completely dried.

Crime laboratories may also request collection of a vaginal washing. For this procedure, insert 5 mL of sterile (but not bacteriostatic) water or saline into the vagina and then remove it. Place the washing in a sealed container (such as those used for urine collection or a red-topped blood tube). In addition, collect cervical swabs if the time from assault to examination (the postcoital interval) is longer than 48 hours or if there is a history of recent consensual intercourse as well. The crime laboratory may recover sperm from cervical specimens up to 12 days after coitus.3

Each sample should be labeled separately and the area from which the specimen was collected should be recorded in the chart.

Genital Testing for STDs

Guidelines from the Centers for Disease Control and Prevention (CDC) suggest obtaining a cervical, rectal, or oral specimen for culture or polymerase chain reaction (PCR), or both, for Chlamydia trachomatis and Neisseria gonorrhoeae. However, the majority of SART programs in the United States do not routinely perform these tests.20 STD testing during sexual assault examination can detect only infection before the assault and provides no meaningful information for the crime laboratory. In addition, routine prophylactic treatment with antibiotics effective against N. gonorrhoeae and C. trachomatis makes detection of these preexisting infections superfluous; however, clinicians might want to consider obtaining samples for culture from child victims, in whom the presence of an STD would be indicative of previous sexual contact.

Perineal Toluidine Blue Dye Staining

Toluidine blue dye is a nuclear stain, also used for cancer detection and mast cell staining, that highlights areas of injury. It adheres to areas denuded by abrasions and lacerations where the epidermal layer of nonnucleated cells has been removed (Fig. 58-10). The underlying nucleated cells take up the dye. Although it is not a uniform standard of care and unavailable in many EDs, the dye can enhance the examiner’s ability to visualize and photographically document more subtle genital injuries (see Fig. 58-6

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