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.

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.

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). Genital lacerations may provide corroborating evidence of nonconsensual intercourse, or at least sexual activity. To outline injuries, apply a 1% aqueous solution of toluidine blue dye to the perineum and wipe the excess dye off with a cotton ball moistened with lubricating jelly. A swab containing the dye is commercially available. After the excess dye is removed, any areas that retain the stain signify a disruption in the epidermis, most likely injury. Separate any folds of the area and carefully examine them to avoid missing injuries. Ideally, apply the dye before speculum examination to eliminate the possibility of iatrogenic injury. The procedure is described in Figure 58-10 and Box 58-2. In one study, use of toluidine blue dye increased the injury detection rate from 16% to 40% in women without the use of colposcopy²¹; however, injuries detected with the aid of toluidine blue dye are not 100% specific for sexual assault because such injuries have also been found after consensual intercourse, especially in adolescents.²²

Collect external genital samples before the application of toluidine blue to avoid washing away potential DNA evidence. The use of toluidine blue dye itself does not interfere with DNA evidence from vaginal specimens, and it has proved safe for mucosal application.23–25

Anal Evaluation

The anal examination follows the genital examination in most cases (Fig. 58-11). Documentation of anal penetration holds significant value because it is a separate crime in addition to vaginal penetration and may increase criminal penalties against convicted sexual predators. Separate the anal folds to look for lacerations and abrasions, and if desired, apply toluidine blue as outlined in the genital section. Collect two external anal swabs before applying the dye. Clean the dye off thoroughly. If anoscopy is not planned, collect the internal rectal sample as follows: separate the anal folds as much as possible and insert swabs approximately 2 cm into the anus. Gently move them in a circular motion and then remove them. Use the swabs to make slides, air-dry them, and include them in the evidence sent to the crime laboratory. Use toluidine blue dye, as described earlier, to better visualize injuries. Anoscopy is indicated to document potential rectal injuries in victims who report anal penetration or describe loss of consciousness during the assault. Perform this procedure in the same manner as diagnostic anoscopy done to evaluate other anal or rectal emergencies in the ED. It is best to collect the internal rectal specimens at the end of the anoscope to prevent contamination from any external sample being dragged internally. In one retrospective observational study of male victims, the use of anoscopy and colposcopy provided superior documentation of injuries over colposcopy alone.²⁶ The location of anoscopically detected injuries may be recorded geographically on an imaginary clock face as with vaginal injuries.

Reference Samples

Crime laboratories may request reference samples from various locations on the victim’s body to use in comparison testing with potential evidence from the perpetrator. These reference samples include blind swabs on the victim’s skin in a location complementary to suspicious skin samples. For example, if a suspicious discharge is swabbed from the victim’s right shoulder, take a control swab from the victim’s left shoulder as well. Crime laboratories may also request other control samples for reference to the victim’s DNA, such as blood, buccal mucosa cells, head hairs, or pubic hairs. The need for such samples will be determined by local protocol.

Blood Tests

Some crime laboratories request blood samples for DNA reference, toxicology analysis, or both. Include these samples with the material sent to law enforcement. When collecting blood for toxicology testing, record the exact date and time of collection on the specimen so that the criminologist may estimate the dose and timing of substances used by perpetrators to facilitate the assault.

Urine Tests

Perform bedside urine β-human chorionic gonadotropin (β-hCG) testing in all women victims of childbearing age to exclude preexisting pregnancy before instituting pregnancy and STD prophylaxis. Collect the victim’s first available voided urine as requested by local crime laboratories to optimize recovery of potential toxicology evidence.

Spermatozoa, Semen, and DNA Testing

Motile and immotile sperm may be found microscopically in wet mounts of vaginal aspirates and in vaginal, oral, and rectal swabs. If formally trained, evaluate the slide microscopically immediately after the physical examination. Examiners find sperm in 13% to 26% of vaginal wet mount specimens.13,27 Early discovery of sperm may be helpful to law enforcement investigations. However, most ED examiners lack formal training in this process and crime laboratories possess much higher sensitivity for detection of sperm, thus making a negative initial wet mount unhelpful. For these reasons, many examiners do not routinely perform the wet mount examination.¹³ After consensual intercourse with a normal ejaculate, laboratory testing of vaginal secretions detects sperm in 50% of specimens 4 days after coitus.²⁷ However, despite penile penetration during sexual assault, crime laboratories may fail to detect sperm. Reasons for failure include inadequate specimen collection, degradation of the ejaculate, azoospermia, failure of the perpetrator to ejaculate, vasectomy in the perpetrator, washing by the victim, or use of a condom.

A crime laboratory analyst initially looks for semen in a given sample by searching microscopically for sperm on a concentrated specimen and by testing for other components found in semen. Such seminal plasma components include p30 and acid phosphatase. p30 is a glycoprotein specific to the prostate and is regarded as conclusive evidence of semen (i.e., ejaculation within 48 hours), whereas acid phosphatase is presumptive evidence only because it can occur in other body fluids, such as vaginal secretions.²⁸ Although this was a main component of crime laboratory investigation in the past, many laboratories have abandoned the acid phosphatase test in favor of the more specific p30 test.^28,29 Despite negative testing for seminal plasma components, laboratories may be able to detect valuable DNA evidence from persistent sperm cells or the perpetrator’s epithelial cells.^30,31 As DNA testing technology rapidly changes, the ability of crime laboratories to perform a specific forensic test varies by location and over time. Most crime laboratories look for unique short tandem repeats in perpetrator DNA with PCR amplification testing, which requires minimal material.

Chain of Custody

Give samples and other evidence to the police, a crime laboratory, or a forensic pathologist. Label each sample with the patient’s name, hospital number, date, time of collection, area from which the specimen was collected, and collector’s name. Package these specimens according to local crime laboratory specifications and transfer them to the next appropriate official (police officer, pathologist, or other individual) along with a written chain of custody, including a list of the specimens, the signature of each person who collected them, and the signature of each person who received them. If this chain is broken, important evidence might be deemed inadmissible in court.

STD Prophylaxis

The approach to prophylaxis for potential diseases transmitted by sexual assault vary by region, disease prevalence, and local practice and is often influenced by the emotional state of the victim and personal and religious viewpoints. We present an overview that may serve as a general guideline, with the understanding that many issues are vague, unsettled, and not totally adopted by all clinicians (Box 58-3).

It is advisable to address the issues of STD, pregnancy, psychological distress, and follow-up in the treatment of a sexual assault victim. Because infection rates before the assault are not known, the risk of contracting an STD as a consequence of a sexual assault has been difficult to determine, and estimates vary widely (Table 58-2).³² Jenny and colleagues found the postassault incidence of STDs to be 2% for Chlamydia and 4% for gonorrhea.³³ The reported rates of 12% for Trichomonas and 19% for bacterial vaginosis seem high and may reflect a preexposure infection because male transmission of these infections, especially bacterial vaginosis, is uncommon. We lack specific data on risk for the development of herpes, hepatitis B, or human immunodeficiency virus (HIV) infection from sexual assault. However, HIV transmission has been noted.³⁴

Because victims tend to have relatively low compliance with keeping follow-up visits, most examiners offer, at the least, treatment of gonorrhea and Chlamydia at the time of the initial examination.²¹ Though most often termed prophylaxis, technically this antibiotic administration is considered “treatment” given so early that the disease is subclinical. The need for routine administration of medication to combat Trichomonas is unclear, and many clinicians do not recommend it as a routine intervention. Prophylaxis for bacterial vaginosis is rarely suggested.

With the increasing prevalence of antibiotic-resistant N. gonorrhoeae, ceftriaxone and cefixime have become the CDC’s recommended antibiotics of choice in targeting gonorrhea after sexual assault. Ceftriaxone also treats incubating syphilis. (The World Health Organization [WHO] also considers a 2-g dose of azithromycin to be effective against incubating syphilis.) No single-dose regimen for gonorrhea is effective against coexisting C. trachomatis infection. Therefore, give patients either a single dose of azithromycin (1 g orally) or a 7-day course of doxycycline (100 mg orally twice a day) or tetracycline (500 mg orally four times a day). A negative pregnancy test is a prerequisite for using either of the latter two antibiotics. Erythromycin may be used as a second alternative for Chlamydia prophylaxis in a pregnant patient. Some examiners administer prophylaxis for Trichomonas with a single 2-g oral dose of metronidazole; although effective and recommended by the CDC,³⁵ this dose of metronidazole may cause significant nausea, vomiting, and diarrhea, which can interfere with the efficacy of pregnancy prophylaxis. Box 58-4 provides several options for STD prophylaxis.

Prevention of Hepatitis B

Most sexual assaults involve perpetrators whose hepatitis B status is unknown. In these cases, the CDC recommends hepatitis B vaccination at the time of examination, followed by two more vaccines at the age-appropriate vaccine dose and schedule for previously unvaccinated victims.³⁵ Give the vaccine to victims as soon as possible after the assault. The CDC recommends that it be given within 24 hours, but this may not be possible in all cases. When a perpetrator is known to be hepatitis B antigen positive and the victim is known to be hepatitis B antigen negative and has not been adequately vaccinated, the CDC recommends the administration of hepatitis B immune globulin (HBIG) in addition to vaccination. HBIG is not recommended if the patient is first seen by medical providers 14 days or more after the sexual exposure. Hepatitis B vaccine should be administered simultaneously with HBIG in a separate injection site, and the vaccine series should be completed at subsequent visits. Complete CDC recommendations for treatment of hepatitis B and other sexually transmitted infections in sexual assault victims can be found at http://www.cdc.gov/std/treatment/2010/sexual-assault.htm.

Prevention of HIV Infection

In a non–assault-related scenario, the risk for transmission of HIV from one episode of unprotected consensual receptive vaginal intercourse with an infected individual is approximately 1 in 1000. The incidence with unprotected receptive anal intercourse is significantly higher at 8 to 32 per 1000.³⁶ However, sexual assault victims often sustain tissue injury because of the violent nature of the act, which may increase the rate of transmission of the virus. Although postexposure prophylaxis (PEP) for parenteral occupational exposure to infected body fluids (i.e., needlestick) is believed to be effective based on case-control studies, there is no proof that PEP for human sexual exposure prevents transmission of the virus.³⁷ Furthermore, victims of sexual assault frequently arrive for treatment much later than those who have occupational exposures.

However, 40% of sexual assault victims fear contracting HIV after assault and should, at a minimum, receive counseling and, some argue, the option of taking anti-HIV medications because they may be effective.38,39 Unfortunately, immediate testing of the perpetrator remains a remote option. The majority of cases lack a perpetrator in custody for testing, and few state laws provide for legal preconviction HIV testing of alleged perpetrators.⁴⁰ In 2005 the U.S. Department of Health and Human Services Working Group on Nonoccupational Postexposure Prophylaxis recommended administering PEP to sexual assault victims only in cases in which the perpetrator is known to be HIV positive.⁴¹ This recommendation specifies a 28-day medication course for sexual assault victims who arrive for care less than 72 hours after the event with an HIV-positive perpetrator when that exposure represents a substantial risk for transmission (i.e., mucosal contact with genital secretions). As with occupational exposure, antiretroviral medications should be initiated as soon as possible after exposure. For sexual assault exposure with a perpetrator of unknown HIV status, the working group declined to offer a recommendation concerning antiretroviral administration; this must be addressed by practitioners on an individual case-by-case basis.⁴² Given the extreme negative outcome, the relative safety of treatment, and the lack of conclusive scientific evidence, at least two states have written policies to guide examiners in this complex issue. One such policy is shown in Table 58-3.

Pregnancy Prophylaxis

Pregnancy occurs in up to 4.7% of sexual assault victims.⁴³ An estimated 22,000 annual rape-related pregnancies could be avoided if all victims received pregnancy prophylaxis within 72 hours.⁴⁴ Perform a urine pregnancy test before administering postcoital contraception (PCC). Modern urine pregnancy tests possess a detection threshold approaching 20 to 25 mIU/mL and will usually be positive 1 to 2 weeks after conception, often before a menstrual period is missed.

Offer pregnancy prevention with available oral PCC to all sexual assault victims. Several methods can be used to prevent pregnancy after assault (Table 58-4). The drug of choice for PCC is levonorgestrel, which is available in the United States in a commercial kit called “Plan B,” “Plan B One-Step,” or “Next Choice.” The U.S. Food and Drug Administration (FDA) approved the sale of Plan B without a prescription for individuals 17 years or older. Although the original Plan B kit included two pills containing 0.75 mg of levonorgestrel, each approved for administration 12 hours apart, a large WHO trial demonstrated that both pills may be taken at once with the same efficacy as the divided dose and the potential for increased compliance.⁴⁵ The newer Plan B One-Step is a single 1.5-mg pill to be taken as outlined in the WHO study. In the rare instance in which levonorgestrel is unavailable, there are several combined oral contraceptive pills, known as the Yuzpe regimen, that may be used for PCC (see Table 58-4).⁴⁵ The Yuzpe method is somewhat less effective but prevents approximately 75% of pregnancies that would otherwise have occurred.⁴⁵ Plan B prevents 89% of pregnancies that would otherwise have occurred and causes fewer side effects. Potential adverse side effects of both methods include nausea, vomiting, and breast tenderness. If the patient vomits within 1 hour of taking a dose, repeat the dose. Some practitioners routinely offer prophylactic antiemetic therapy; others reserve such treatment for patients who vomit. In 2010 the FDA approved a third option for pharmacologic emergency contraception, ulipristal acetate (brand name ella). This selective progesterone receptor modulator has been demonstrated to be as effective as levonorgestrel for prevention of pregnancy 72 hours after intercourse and more effective for longer postcoital use. Ulipristal requires a prescription and is approved for use up to 120 hours after intercourse.⁴⁶

All available evidence demonstrates no untoward effects on the fetus should pregnancy occur despite PCC.⁴⁷ The common practice of obtaining written patient consent for these medications seems unwarranted.

Unfortunately, religious preferences may deter some hospital EDs from providing PCC.⁴⁸ In these instances, the website and number listed at the end of this paragraph provide practitioners information to give referral for easy access to PCC for patients who cannot obtain Plan B (i.e., those younger than 17 or lacking funds to pay for the medication). In addition, given the ever-increasing availability of new methods and drugs for PCC, examiners may want to obtain up-to-date information from this site (www.not-2-late.com; telephone: 1-800-not-2-late).

Psychological Support

Sexual assault precipitates a psychological crisis for the patient, and psychological care should begin when the patient first arrives in the ED.49,50 Reassure the victim that she will be in control of the examination, that she may ask questions at any point, and that she should notify the examiner if anything hurts or if she needs a break. Giving the victim control over her body and the examination is the first step toward psychological support. Unfortunately, if this is not made a priority, full recovery may be impaired. Posttraumatic stress disorder (PTSD), manifested as numbed responsiveness to the external world, disturbances in sleep, feelings of guilt, memory impairment, avoidance of activities, and other symptoms, often develops in sexual assault victims.⁵¹ Rape trauma syndrome is the specific label for PTSD in this population.⁵² Rape trauma syndrome stems from the following characteristics of sexual assault: (1) it is sudden and the victim is unable to develop adequate defenses, (2) it involves intentional cruelty or inhumanity, (3) it makes the victim feel trapped and unable to fight back, and (4) it often involves physical injury. Attention to the initial psychological care of a rape victim in the ED is fundamental and can reduce distress during forensic examination.⁵³

Many areas have a local sexual assault crisis agency that can dispatch an advocate to be with victims during the interview and examination. This same agency may then provide the follow-up psychological support that must be offered to all victims. It is critical that all examiners maintain current contact information with these agencies and use their services. The importance of this contact is emphasized in some areas by the fact that state law dictates that medical personnel contact a local sexual assault crisis agency when a victim arrives for examination (California penal code 264.2, Notification of a Counseling Center). In the absence of immediate local crisis services, a hospital social worker may fill this role.

Postexamination Follow-Up

Medical and psychological follow-up of sexual assault victims is essential. Unfortunately, less than one third of victims complete follow-up medical care.⁵⁴ Many protocols recommend a 2-week follow-up to reexamine any injuries and to repeat testing for STDs and pregnancy. The timing of this follow-up seems to be less important given the widespread use of prophylactic medication to prevent STDs and pregnancy. However, because of the measurable failure rate of PCC, repeated pregnancy testing is critical for a victim who does not experience an expected menses. Further follow-up evaluations may be performed at 4 or 6 weeks and 4 to 6 months to repeat serologic tests for HIV, hepatitis B, hepatitis C, and syphilis. In addition, local volunteer support groups can be of immense assistance to a sexual assault victim; contact with such a group should be offered to each victim.

Male Evidentiary Examinations

Male evidentiary examinations include all of the same forensic evidence collection as for female victims except vaginal and cervical specimens. As with all victims, the forensic examination is guided by the history of events related by the victim. Most male victims suffer from anal penetration, or sodomy, by a perpetrator. In addition to rape trauma syndrome, heterosexual male victims may suffer psychological trauma and wonder whether the assault dictates a change in their sexual orientation. Examiners should inform such victims that forced sodomy does not indicate subsequent sexual orientation as a victim may believe that suffering sodomy makes one a homosexual. The increased risk for transmission of HIV with anal intercourse has been noted (see “Prevention of Human Immunodeficiency Virus Infection” earlier in this chapter). Because of the extreme emotional reaction that men often feel after a sexual assault, they report the crime even more sporadically than female victims do.54,55 Male victims deserve the same unhurried, nonjudgmental manner that female victims do. Penile samples from the shaft, glans, corona, and scrotum may be obtained if there is oral or anal contact with the perpetrator.

Child Sexual Assault Examinations

In general, the care and treatment of a pediatric sexual assault patient requires expert knowledge and experience. Frequently, ED practitioners are the first professionals to examine a child victim, and based on the history provided, the presence of obvious genital injury and trauma may speak for itself. However, in less obvious cases, the subtle variations in developmental changes and congenital anomalies may leave many clinicians ill equipped to render an opinion concerning findings indicative of sexual assault. The lives of children and families may be disrupted or severely affected, depending on the practitioner’s opinion of the presence of genital penetration–type findings.

A well-known study by Adams and associates demonstrated that the majority of children reporting sexual abuse have normal or nonspecific genital findings.⁵⁶ As these authors succinctly stated regarding child sexual assault, it is “normal to be normal.” Despite expert physical examination, the vast majority of sexually abused children cannot be differentiated from nonabused children.⁵⁷ Discovery of one of the rare examination markers of injury should be confirmed by experts, and a discussion of these findings, though beyond the scope of this chapter, is covered extensively in other resources.⁵⁸ The potential sexual assault history provided by the child or caretaker should therefore remain the primary indicator that inappropriate genital contact has occurred. At the very least, the history warrants an investigation of the possibility of sexual abuse.

It cannot be emphasized enough that the examiner’s responsibility in the care of a child victim of sexual abuse remains within the realm of experts. However, in EDs lacking timely availability of local experts, inspect the genitalia carefully in an unhurried, child-friendly manner, and if indicated, collect forensic specimens. For a very young child with small genital orifices, the aid of a magnification source may be extremely helpful. Ask a parent to assist in the calming, reassurance, and positioning of the child for careful inspection. However, when the parent is a suspect, the practitioner must exclude that parent from the examination. Whereas the basic lithotomy position may be used for an older, more mature child or an adolescent patient, use of alternative positioning of a pediatric female patient is essential for inspection. The frog leg position (the feet together and the knees spread widely apart) with the use of labial or gluteal (or both) separation and traction is often beneficial in children (Fig. 58-12). Take care to gently separate the labia to avoid superficial examiner-induced injuries. In addition, to get a better look at the hymenal perimeter in prepubertal girls and the anus in girls and boys, ask them to turn over into the knee-chest position (Fig. 58-13). Genital findings that are deemed definitive of sexual abuse or penetration or are nonspecific are included in Box 58-5. However, many normal hymenal differences exist from one child to the next, and the definitive diagnosis of “abnormal” is often difficult even for experts. When any doubt exists in the ED, describe the findings and refer the child for later examination by experts. The availability of a colposcope or alternative photographic equipment with magnification clearly aids in the documentation of any injuries that may heal before examination by an expert can be performed.

When disclosure or genital injuries confirm possible penetration of the child, collect specimens for potential evidence. On all conscious prepubertal children, collect the specimens without inserting a pediatric speculum. If there is no bleeding or significant trauma, procedural sedation is rarely indicated. If a child proves to be too uncooperative for an ED examination, refer the patient to a child sexual assault expert for examination the next day. For the rare cases involving severe vaginal trauma or suspected internal genital injury (active bleeding) that will possibly require surgical repair, conduct the examination under deep procedural sedation or general anesthesia. External anal and vulvar swabs are usually collected without difficulty on a child of any age. Because of lack of estrogen, contact with the prepubertal hymen generates much pain, thus making vaginal samples difficult to obtain. The samples should remain the very last evidence collected. Make every effort possible to avoid swab contact with hymenal tissue during collection. Vaginal aspirates obtained with a feeding tube or plastic angiocatheter may provide an alternative to vaginal swabs.

Genital specimens to screen for STDs remain a controversial issue in the realm of child abuse experts. For N. gonorrhoeae, at least, the literature supports the notion that all infected children will display an abnormal discharge.⁵⁹ With very young children, the practitioner may have only one opportunity to collect vaginal specimens without causing agitation prohibiting further examination. Forcing specimen collection under physical restraint is considered a second assault on the child. Because the child is being evaluated for possible sexual abuse, the primary specimens collected should be for forensic DNA analysis. STD detection and treatment can be performed at a later time. Clinicians should consult local child abuse centers for protocols regarding immediate STD specimen collection, referral, and follow-up services.

Suspect Examinations

As forensic evidence collection in the form of DNA retrieval continues to evolve, EDs may see more requests from local law enforcement for collection of evidence from suspects. EDs should be familiar with local and state protocols, especially regarding consent. Some jurisdictions permit examination of suspects without consent given the imminent degradation of potential biologic evidence. Other jurisdictions require that suspects give consent or, at the very least, that police obtain a search warrant from the court. The sooner that a suspect is apprehended and brought in for a medical-forensic examination, the better the quality of forensic biologic evidence.

Performing a medical-forensic examination on a suspect can give important corroborating information for the investigation of a crime. It can also help exonerate the innocent. Law enforcement should always be in attendance during the examination of any suspect to ensure the safety of the examiner. The suspect and victim should never encounter one another in the hospital setting during the examination period, and care should be taken to examine the victim and suspect in separate locations within the ED or clinical setting. It is extremely beneficial to conduct the examination and history of the victim before the suspect’s examination to search for physical findings on the suspect indicated by the victim’s history. For example, if during the victim’s history she relates that she scratched the suspect’s left shoulder in defense, the examiner can be certain to examine, document, and preferably photograph the presence (or absence) of an injury on the suspect’s left shoulder.

The physical and evidentiary examination of the suspect is similar to that of the victim. The primary differences lie in history taking, reference samples, and more “blind” samples. During the examination of a suspect, law enforcement officers rather than the suspect provide the history of the event. Collect reference samples of head and pubic hairs, as well as blood, saliva, and urine, if possible. Apply special attention not only to nail scrapings but also to swabbing all the fingers for possible vaginal epithelial cells from digital penetration. The shaft and corona of the glans penis should be swabbed along with separate swabs of the scrotum for vaginal secretions. With an unwashed penis, swabs almost uniformly show evidence of female cells up to 24 hours after coitus.³⁰

Examining suspects requires the same amount of professional sensitivity and respect that any patient receives within the ED. It is not within the realm of the clinician’s expertise to determine whether the suspect is guilty or innocent.

The Unconscious Victim and “Drug-Facilitated Sexual Assault”

Alcohol and other drugs play an important role in many sexual assaults. Half of all sexual assaults involve drug or alcohol ingestion.⁶⁰ In many cases it is unclear whether a drug was taken voluntarily or whether it was surreptitiously given to the assaulted victim.

Popular media has raised public awareness of drugs used to facilitate sexual assault under the term date-rape drugs (Box 58-6).⁶¹ Although date-rape drugs are of significant concern, extensive forensic testing in the United States shows that a minority of sexual assault cases involve the scenario in which a victim’s drink is covertly spiked with a tablet, capsule, powder, or liquid containing mind-altering drugs.⁶² However, laboratory testing may be inadequately sensitive to test for all substances used during drug-facilitated sexual assault. The drugs most commonly associated with drug-facilitated sexual assault are ethanol, marijuana, cocaine, and benzodiazepines. Frequently, more than one drug is found. Although any type of sedative or hypnotic drug, or a combination of both, may be used to facilitate sexual assault, the most publicized drugs include flunitrazepam (Rohypnol), γ-hydroxybutyrate (GHB), and most recently, beverages containing high amounts of alcohol and caffeine (for example, Four Loko).^62,63 In previous decades, laboratory testing implicated flunitrazepam and GHB in drug-facilitated sexual assault in approximately 3% to 5% of cases.⁶¹ Flunitrazepam is a benzodiazepine unavailable in the United States but available in Mexico. It can be detected in urine up to 3 weeks after ingestion.⁶⁴ In the United States, GHB is a schedule 1, federally banned central nervous system depressant. Legally, it is available only by prescription as the drug Xyrem for narcolepsy with a schedule 3 exception, but it can easily be manufactured illegally by users. It can be detected in drinking material residue by crime laboratories as well in the victim’s urine up to 4 hours after a sufficiently large ingestion. Drugs similar to GHB are 1,4 butanediol and γ-butyrolactone.

Often, the victim’s last memory is of using drugs or alcohol and then passing out. A common scenario is for the victim to have one glass of wine (or other usual drink), suddenly feel nauseated, and then wake up hours later in a different location and lacking intervening memory. Some remember short segments of activity that may indicate some type of sexual acts. Victims may lack any memory at all but desire to be “checked” for intercourse. A comprehensive medical-forensic examination should be conducted on these individuals. Without a history from the victim, examiners must collect samples from every potential oral or genital contact, including the neck, breasts, and vulva and from all orifices (oral, vaginal, and anal). Obtain samples of both blood and urine, if possible, for toxicology (including ethanol), with exact times of collection documented. Remember to collect the first voided urine to optimize potential recovery. Many of the drugs used to facilitate sexual assault are not found on routine hospital laboratory testing. Some forensic laboratories offer a “date-rape panel” that tests for a variety of commonly used substances. Obviously, a positive drug test does not prove date rape, and it may be impossible to distinguish self-administration from clandestine ingestion.

Extreme sensitivity must be used when discussing positive genital findings with a victim who has no memory of any sexual activity. Many times the imagined sexual acts can create just as severe a traumatic response as an actual remembered sexual assault. For the unconscious victim, there is no memory of events to fill in the blanks, only her terrifying imagination of what could have happened.

1. The practitioner performing the examination is specifically dedicated to treating the victim, not tending to multiple patients in a busy ED.

2. The clinician has usually completed more extensive training on sexual assault examination (mean of 80 hours) and evidence collection and, accordingly, may perform a more comprehensive examination with better collection of evidence.21,65

3. Many involved feel that designated clinicians consider the emotional needs of the victim more fully because of their extra specialty training.

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