Examination of the Sexual Assault Victim

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 of assailants and the exoneration of wrongly accused subjects.

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 (e.g., The Lynn Peavey Company, https://www.lynnpeavey.com ). Prepared kits can save a tremendous amount of nursing and clinician time. A checklist of local requirements for sexual assault examination should be included in the kits and serves as a reminder for all the necessary medicolegal procedures to be completed.

Although this chapter is devoted primarily to the evaluation of adult female sexual assault patients, guidelines for the evaluation of adult male sexual assault patients, female child patients, male child patients, 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 patient often requires considerable expertise and training. When possible, medical staff with specialized training in the examination of child sexual assault patients should perform these examinations. If this is not possible, the section on Child Sexual Assault Examinations should provide emergency medical personnel with a basic framework to perform an initial examination .

Consent

Consent for the evaluation and treatment of a sexual assault patient is mandatory. The patient has undergone an experience in which her/his right to grant or deny consent was taken from her/him, and obtaining consent for medical treatment and gathering evidence has important psychological and legal implications. The patient 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, patients may choose to not discuss the event with police. If the patient cannot give consent for a forensic examination because of a reversible process (e.g., intoxication, an acute psychological reaction), wait several hours for the patient's mental status to improve to a reasonable level before consent is obtained. When patients 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 patient 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 patient 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 counsel 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 documentation 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 patient, and any loss of consciousness experienced by the patient. Sexually assaultive acts may include manual or oral 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, ecchymosis, and scratches) with a description of any force, restraint, or violence.

Clearly indicate the patient's post-assault activity, which is commonly requested on the necessary documentation, 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 because perpetrator DNA has been recovered from the patient's skin even after multiple showers. In addition, obtain a good history from the patient about potential injuries and any body trauma that may have occurred 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 19 days after intercourse and from the vagina for up to 10 days ( Table 58.1 ). Cervical samples are now recommended 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, inquire 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 impaired consciousness. Patients 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 patient 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. As always, patiently explain every step of the examination process to the patient. Remind the patient to communicate any discomfort or questions during the examination and to ask for a break from the examination if needed. In addition, remind the patient of her right to decline any portion of the examination and the ability to stop at any point. Each patient 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, if they so desire.

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 ( Fig. 58.2 A ). Injury to the lips is often produced by the patient'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 contusions, submucosal hemorrhage, and lacerations (see Fig. 58.2 B ). 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. 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 patient's pubic hair for foreign material (particularly pubic hair belonging to the assailant). Place clean paper below the victim's buttocks with the patient 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. For the small minority of cases in which crime labs desire to compare foreign suspect hairs with the victim's hair, a sample pulled from the patient may be requested. 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. Additionally, many agencies perform DNA testing on any hair recovered initially, rendering microscopic comparison with victim hairs superfluous. In the very rare case when it is requested, a patient can provide the hairs at a later time.

Genital examination of a sexual assault patient differs considerably from most ED pelvic examinations. First, carefully explain what you are doing to the patient. Perform a careful visual evaluation of the vulva and vaginal introitus for signs of trauma. The following techniques of separation and traction move the tissues that are most likely to suffer injury into view. In performing separation, use both hands to gently separate the labia laterally in each direction and inspect the posterior fourchette and vaginal introitus. Similarly, in performing traction, 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 these maneuvers are not performed, 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 ). In fact, hymenal injuries are rare in sexually active adult women and are more commonly observed in sexually inexperienced adolescents ( 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 patients range from 6% to 20% without colposcopy to 53% to 87% with colposcopy. Most importantly, examiners must be cognizant of the fact that even completely normal findings on genital examination remain consistent with forced sexual assault. In fact, a study of more than 1000 sexual assault patients found that almost half of all victims with forensic evidence positive for sperm had no genital injury.

Colposcopy

Teixeira first described the use of colposcopy for documentation of sexual assault in 1981. 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%. 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 A and B ). 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 (see Fig. 58.8 C ). 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 translate to nonconsensual vaginal penetration. 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. 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.