Multidisciplinary Approach

Emergency physicians (EPs) are responsible for managing both the medical and forensic needs of patients with a report of sexual assault. This is best accomplished in an organized manner, such as with a sexual assault response team (SART). Members include a sexual assault forensic examiner (SAFE), victim advocates, law enforcement officers, crime laboratory personnel, and prosecutors. A SAFE has specialized knowledge and training to perform the forensic evaluation with a standardized sexual assault evidence collection kit (SAECK). Research has shown that use of a SART/SAFE program improves the quality of forensic evidence with an increase in prosecution rates over time.⁶ In jurisdictions in which such teams are unavailable, ED providers are responsible for the forensic examination, and it is therefore prudent that EPs familiarize themselves with their state-specific SAECK.

Consent for Forensic Evaluation and Evidence Collection

Patients should be informed of all of the options available to them, including forensic evaluation and evidence collection, depending on timing of examination. Before proceeding with any part of this evaluation, written informed consent for all aspects of the evaluation must be obtained as listed in Box 128.1. The patient has the right to refuse all or some parts of a forensic examination, and consent can be withdrawn at any time during the examination.

One Patient, Two Medical Records

The clinical encounter with a sexual assault patient is unique in that two medical records are generated for one patient. One is the usual ED medical record and the other is the forensic legal record. These records serve very different purposes, and consequently what is documented in each will differ.

History

For the ED medical record, the history of the assault should be focused on details that affect medical management of the patient in the ED, including information that will help determine the risk for injuries and what treatment of sexually transmitted diseases (STDs) should be offered. In contrast, the forensic record is driven by strict policies and procedures and should include only medical information that has a direct bearing on evaluation of the reported crime. Material that is generally considered to constitute useful background in a therapeutic context may have a prejudicial effect in a forensic context and should not be included in the forensic record. Examples include the number of previous pregnancies, past mental health treatment, and remote substance abuse. Documentation should be concise and directly relevant to the assault, including any information that is necessary to properly interpret the current physical findings. Many SAECKs contain preprinted forms that help the examiner with the history-taking process to facilitate proper documentation. Salient features of the history that should be obtained for documentation in the forensic medical record are listed in Box 128.2.^7,8

Physical Examination

Physical examination is necessary to evaluate for signs of any trauma sustained during the sexual assault. The reported incidence of nongenital physical injuries ranges from 23% to 85%.^8–15 When injuries are sustained, those most commonly seen are soft tissue injuries involving the head, face, neck, and extremities. Blunt force trauma, including penetrative blunt mechanisms, may produce contusions, which are associated with swelling, pain, tenderness, and discoloration, and lacerations from tearing of the tissues. A friction mechanism may cause abrasions. Sharp-force trauma may produce incised wounds. Bites may involve multiple mechanisms of injury. Patterned injuries suggest the specific object, weapon, or mechanism used to produce its characteristic shape.

The physical examination should be dictated by the history of the events. Close attention should be paid to the skin for signs of victim resistance, applied restraints, or defensive wounds. The oral cavity should be inspected for a torn lingual or labial frenulum or contusions to the palate with report of an oral assault. With a report of strangulation, the examination should focus on assessing for and documenting abrasions or contusions of the neck, facial petechiae, and subconjunctival hemorrhage.

Published rates of female genitoanal injury vary widely from 6% to 65%, with most investigators reporting a range of 10% to 30%.^8–18 Risk factors for injuries included examination within 24 hours of the assault, presence of nongenital injury, threats of violence, and age younger than 20 and older than 40 years.^8–18 The genital structures most frequently injured as a result of a penetrative mechanism are the fossa navicularis and posterior fourchette, followed by the labia minora and hymen. It is paramount that these areas be inspected carefully during the examination.

Physical examination consists largely of gross visual inspection, which may readily miss documentable injuries. Adjuncts to assist in detecting subtle injuries include anoscopy, colposcopy, Wood lamp, and application of toluidine blue.

A large number of sexual assault patients do not sustain obvious injuries. It is important that the EP understand that the absence of objective physical or genital injury does not preclude the possibility of sexual assault. The presence of such injuries is dependent on many assault-specific and patient-specific factors, including the age of the victim, the state of the tissues such as lubrication and elasticity, the degree of force involved, and the use of objects or implements. In addition, detection of subtle injuries is largely dependent on examiner training and experience.

For the forensic record, documentation of the physical findings should include thorough, precise written descriptions in standard anatomic position, including injury location, measured size, shape, colors, contours, and depth. In addition, the use of anatomic body maps and forensic photography is encouraged, both of which can be invaluable in court proceedings. Many SAECK preprinted forms include body maps on which to note injuries.

Forensic Evaluation: Evidence Collection and Chain of Custody

The premise of evidence collection in sexual assault cases is to link the victim and assailant, relate both to the crime scene, identify the assailant via a DNA profile, and establish some features of the crime. The SAECK, also known as a “rape kit,” is stocked in most hospitals and is state specific. It is used to guide the process of evidence collection within 96 to 120 hours (4 to 5 days) of an assault. EPs should familiarize themselves with the SAECK used in their jurisdiction.

Once a patient consents to evidence collection, the steps delineated in the kit should be followed. Evidence collection should be guided by the history of the assault. Box 128.3 lists potential specimens to be gathered for forensic evidence collection.^19,20