Whether out of impulse, compulsion, anger, or the assertion of power, sexual assault is a criminal act of violence imposed on the vulnerable and the innocent, causing immediate physical and emotional suffering and often having long-lasing adverse psychological effect. For health professionals and society as a whole, the prevention of sexual assault is an urgent and complex matter; for nurses and physicians, the proper evaluation, care, and follow-up of these patients are challenging issues that require an informed, multidisciplinary approach. This course will outline the scope of the problem, discuss the key clinical issues, and provide guidelines for the proper evaluation and treatment of sexual assault victims.
This course is designed for all physicians, nurses, social workers, counselors, and allied healthcare professionals involved in the identification and care of patients who have been victims of sexual assault.
NetCE is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. NetCE is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. NetCE, #1092, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org through the Approved Continuing Education (ACE) Program. NetCE maintains responsibility for the program. ASWB Approval Period: 03/13/2016 to 03/13/2019. Social workers should contact their regulatory board to determine course approval for continuing education credits. NetCE is accredited by the International Association for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. This course is approved by the Association of Social Work Boards - ASWB NJ CE Course Approval Program Provider #14 Course #297. Social workers will receive the following type and number of credit(s): General Social Work Practice 3 for the approval period starting 04/23/2015 and ending 04/23/2017.
NetCE designates this enduring material for a maximum of 3 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. NetCE designates this continuing education activity for 3 ANCC contact hour(s). NetCE designates this continuing education activity for 3.6 hours for Alabama nurses. NetCE designates this continuing education activity for 1 NBCC clock hour(s). Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 3 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Completion of this course constitutes permission to share the completion data with ACCME. Social workers participating in this intermediate to advanced course will receive 3 Clinical continuing education clock hours, in accordance with the Association of Social Work Boards. AACN Synergy CERP Category A. NetCE is authorized by IACET to offer 0.3 CEU(s) for this program.
In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353, (valid through December 12, 2017); California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; Florida, Provider #50-2405; Iowa, Provider #295; Kentucky, Provider #7-0054 through 12/31/2017.
In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190; Texas State Board of Social Worker Examiners, Approval #3011; Texas State Board of Examiners of Professional Counselors, Approval #1121; Texas State Board of Examiners of Marriage and Family Therapists, Approval #425.
This course meets the Connecticut requirement for 1 hour of sexual assault education. This activity is designed to comply with the requirements of California Assembly Bill 1195, Cultural and Linguistic Competency.
The purpose of this course is to provide healthcare professionals with the information necessary to appreciate the scope of the problem of sexual assault, to discuss the key clinical issues, and to adhere to guidelines for the proper evaluation and treatment of sexual assault victims.
Upon completion of this course, you should be able to:
- Apply epidemiologic trends and clinical data to current practice so sexual assault victims can be more accurately and thoroughly identified, evaluated, and treated.
- Create an organized best-practice strategy for the clinical assessment and treatment of the patient who has been sexually assaulted.
- Apply knowledge of the type, location, and character of genital and non-genital injuries caused by sexual assault and rape, to assure a comprehensive clinical and forensic physical examination of assault victims.
- Describe key points of the forensic evaluation of sexual assault victims, including best practices for photographic documentation.
- Devise a treatment approach, and select the appropriate drug regimen and/or consultation needed, for prophylaxis against sexually transmitted infections (STIs) and prevention of pregnancy.
- Anticipate the immediate and long-term emotional and psychological impact of sexual assault, and arrange for appropriate crisis intervention and follow-up care.
John M. Leonard, MD, Emeritus Professor of Medicine, Vanderbilt University School of Medicine. Dr. Leonard completed his post-graduate clinical training at the Yale and Vanderbilt University Medical Centers, and then joined the Vanderbilt faculty in 1974. He has served as director of educational programs for the Department of Medicine and was the Residency Program Director from 1981 to 2003. Dr. Leonard's clinical experience includes an active practice of general internal medicine and an inpatient consulting practice of infectious diseases.
Contributing faculty, John M. Leonard, MD, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
John V. Jurica, MD, MPH
Jane C. Norman, RN, MSN, CNE, PhD
Alice Yick Flanagan, PhD, MSW
The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.
Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.
It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.
Supported browsers for Windows include Microsoft Internet Explorer 9.0 and up, Mozilla Firefox 3.0 and up, Opera 9.0 and up, and Google Chrome. Supported browsers for Macintosh include Safari, Mozilla Firefox 3.0 and up, Opera 9.0 and up, and Google Chrome. Other operating systems and browsers that include complete implementations of ECMAScript edition 3 and CSS 2.0 may work, but are not supported.
#97020: Sexual Assault: Evaluation and Care
Sexual assault may be defined as any nonconsensual sexual act carried out by one person upon another by use of force or threat of violence or in the absence of the victim's ability to resist or give consent. Whether out of impulse, compulsion, anger, or the assertion of power, sexual assault is a criminal act of violence imposed on the vulnerable and the innocent, causing immediate physical and emotional suffering and often having long-lasting adverse psychological effects. Rape is the legal term for a sexual assault during which there is penetration of a body orifice (vagina, anus, or mouth) involving force, the threat of force, or incapacity and nonconsent of the victim.
For health professionals and society as a whole, the prevention of sexual assault is an urgent and complex matter; for nurses and physicians, the proper evaluation, care, and follow-up of these patients are challenging issues that require an informed, multidisciplinary approach. The purpose of this course is to indicate the scope of the problem, to discuss the key clinical issues, and to provide guidelines for the proper evaluation and treatment of sexual assault victims.
Although victims of sexual assault are overwhelmingly adult women, the problem is encountered among persons of diverse age and gender. In 1995–1996, a national survey of 8,000 women and 8,000 men found that 1 in 6 women and 1 in 33 men had experienced an attempted or completed rape at some time in their lives . One-half of the female victims indicated that they had been assaulted before their 18th birthday. Most rape victims knew their assailant, and only 1 in 5 reported the assault to the police. Based on these data, the lifetime prevalence for sexual assault in the United States is estimated to be 18% for women and 3% for men. Given the complexity of the problem and the limited methodology of reported studies, most of which are survey-based, the actual prevalence is judged to be greater than these data indicate . Groups of individuals at increased risk for sexual assault include college students, children and adolescents, the mentally disabled, the homeless, and persons who are gay, lesbian, bisexual, or transgendered [3,4]. Sexual assault involving young adults using alcohol and drugs is increasingly recognized and a substantial problem on college campuses .
The problem of sexual assault of young women on and around college campuses was the subject of an extensive and carefully designed collaborative study by two large universities, reported to the National Institute of Justice in 2007 . A web-based survey involving 6,800 undergraduate students (5,466 women and 1,375 men) revealed that 13.7% of women had been victims of at least one completed sexual assault since entering college. The majority had known or had previously seen or talked to their assailant. In addition, 7.8% of women surveyed reported having been assaulted when incapacitated by or after voluntarily consuming alcohol or drugs. Of those who were incapacitated at the time of the assault, 89% reported drinking alcohol and 82% reported being drunk prior to the assault. This study demonstrated :
One in five college women experience an attempted or completed sexual assault during college years.
The majority of assaults occur when women are incapacitated by their use of alcohol.
Freshmen and sophomores are at greatest risk.
The majority of women are victimized by men they know or trust, rather than by strangers.
Victims of sexual assault are most likely to present to hospital emergency departments (EDs), public health and gynecology clinics, college infirmaries, and primary care offices. Published clinical series from urban EDs have helped define the scope and character of sexual assault injury [7,8,9]. Based on these clinical reports, it may be seen that victims of sexual assault presenting to an ED are predominantly female, relatively young, often know their assailant, and are likely to have been threatened with violence and to show physical signs of trauma.
In one such study of 1,076 cases seen between 1992 and 1995, the age of victims ranged from 1 to 86 years (half were younger than 26 years of age) and 96% were women . In 60% of cases, the assailant was someone known to the victim. Force was used in 80% and a weapon was present in 27% of incidents. Vaginal penetration was documented in 83% of cases, oral assault in 25%, and anal penetration in 17%. Signs of genital trauma were evident in 53% of cases, and extra-genital trauma was noted in 67% of victims. Similar results were found in an ED study of 1,100 patients published in 2009. In this study 92% of victims were female, and the median age was 27 years. The majority of victims (57%) knew their assailant. Threat of force was used in 72% of cases, and physical trauma was evident in 52% of victims . Alcohol consumption or drug use was involved in 54% of these assaults.
The residual physical, psychological, and social consequences of sexual assault are considerable. In addition to the potential risk for acquiring a sexually transmitted infection (STI), approximately 1% to 5% of rape victims become pregnant . The National Violence Against Women Survey (NVAWS) found that 33% of women and 24% of men received counseling from a mental health professional as a direct result of their last assault; 28% and 10%, respectively, lost time from work .
The proper clinical assessment of a person who has been sexually assaulted requires a systematic, patient, and thorough approach. It is of necessity time-consuming and should be conducted with sensitivity and respect for the patient's emotional state. Preferably, providers who have been specifically trained for this task should perform the acute clinical examination. More than 500 hospitals and other health facilities in the United States have now addressed this need by adopting the Sexual Assault Nurse Examiner (SANE) program. A SANE is a trained nurse specialist who works within a multidisciplinary team to carry out a general and forensic clinical examination of the sexual assault patient and to develop a strategy for support and after-care .
General assessment and treatment of physical injuries, with special attention to the genitalia
Forensic evaluation, where indicated and with informed consent
Pregnancy risk assessment and prevention
Evaluation, treatment, and prevention of STIs
Psychological assessment, crisis intervention, and follow-up referral for counseling
The initial clinical assessment includes a careful history and physical examination, followed by selected laboratory testing and radiographic studies as indicated by clinical findings. Physical signs of bodily injury are present in more than half of all persons examined after sexual assault, and virtually all patients will appear emotionally distraught, embarrassed, and fearful [7,8]. Specific needs to be addressed include general medical care and assessment of injury, an explanation of all facets of the clinical and forensic evaluation, a description of options for care, and provision of support for patient and family. Cases of sexual assault also carry the parallel consideration of potential criminal prosecution of the assailant and thus the need to inform authorities and to collect and preserve evidence.
Patients who present within the legal time frame for evidence collection should be referred for evaluation by an ED or treatment center with resources and staff trained for this purpose. The specified time limit varies among states and municipalities, usually ranging from 72 to 120 hours. Clinical care providers should inform themselves as to the time frame within their own jurisdiction. Where possible, the evaluation should be conducted by a multidisciplinary team that includes an emergency medicine physician, a trained nurse examiner (i.e., SANE), and a rape crisis counselor or social worker. The patient should be offered a formal forensic examination. This is optional and requires informed consent. The general approach to the history and physical examination is outlined in the following sections, followed by an expanded, detailed review of the principles that pertain to the forensic evaluation.
In the multicultural landscape of the United States today, interpreters are a valuable resource to help bridge the communication and cultural gap between clients/patients and practitioners. If a patient has limited English proficiency, a medical interpreter (live or over the phone) should be accessed. Due to the sensitive nature of the evaluation, some patients will be embarrassed to discuss the matter with a third party. Even if an interpreter is initially declined by the patient, continue to assess the necessity of interpretation assistance. Family members are not considered appropriate interpreters.
Non-genital bodily injury is seen in more than half of all rape victims presenting to EDs [7,8]. In one study of 162 women examined between 2002 and 2006, signs of bodily injury were found in 61% of patients, with genital injury present in 39% . Most common were bruises (56%) and abrasions (41%), followed by lacerations, penetrating injury, and bites. Evidence of injury was higher in the 137 cases examined within 72 hours of assault (66% vs. 33%) and in cases in which the assaults occurred outdoors (79% vs. 52%).
On examination, one should inspect carefully for evidence of blunt traumatic injury to the head, neck, arms, legs, and torso, looking for signs of penetrating injury, lacerations, and bite marks. Bruising may be evident on the neck (attempted strangulation), hands, arms, breasts, or thighs. Signs of bodily injury are more prevalent in women younger than 30 years of age. Other factors showing a strong positive association with bodily injury include alcohol consumption, history of prior assault, and assault by strangers .
Signs of genital traumatic injury are not always found after sexual assault, and in such cases should not be taken as evidence that sexual assault did not occur . When routine inspection is combined with additional examination techniques, such as colposcopy and toluidine blue staining, the rate for identifying genital injury approaches 70% . Observed rates of genital injury are highest in women examined within 72 hours (40% vs. 7%), in those of virginal state (60% vs. 33%), and in cases involving assault by strangers or multiple assailants .
The common types and location of genital injuries, and thus the areas to be examined most closely, are:
Bruises and abrasions to the labia, fossa navicularis, or perianal area
Ecchymoses, tears, or lacerations of the hymen
Abrasions and/or tears of the posterior fourchette
Tears/lacerations in the perianal area
Ideally, the victim of a sexual assault should be offered a formal forensic evaluation. As noted, this is optional and requires written documentation of informed consent. A growing number of hospitals now employ dedicated forensic nurses, including SANEs, as part of a multispecialty sexual assault team .
SANEs have completed specialized training in the medical forensic care of the patient who has experienced physical violence, abuse, or sexual assault. An important component of the care offered by the SANE is the medical forensic examination. This consists of a medical forensic history, a detailed physical and emotional assessment, written and photographic documentation of injuries, and collection and management of forensic samples. The SANE is trained to ensure that evidence is collected and documented according to established protocol and local jurisdiction procedures and that the "chain of custody" is properly maintained in the event of later legal proceedings. Evidence collection kits designed for this purpose are available commercially or, in some states, may be obtained through designated distribution centers.
Often, however, these trained specialists are not the first professionals to interact with the patient. Consequently, all healthcare professionals, particularly those in an emergency care setting, should have an understanding of the principles that govern proper collection and preservation of evidence during the examination of an assault victim. At stake is the successful prosecution of the assault perpetrator, which often is compromised by insufficient or improperly collected evidence or by not following evidence through the chain of custody.
Nursing staff in EDs and clinics are often the first to interact with assault victims and their families. The ability to quickly recognize forensic issues, and thus direct the subsequent course of the evaluation, is a valuable skill to possess [14,15]. Although lifesaving measures take priority over considerations of evidence preservation, it should be recognized that quality of life could be significantly impacted for those whose assailant is not brought to justice.
Accurate and thorough forensic evidence is crucial to the successful arrest and prosecution of a criminal assailant. Evidence of the use of force and the assailant's identity and possible ties to the victim should be gathered to aid law enforcement in their investigation. It is essential that evidence remains intact as much as possible until proper collection and documentation is completed. It is equally important to accurately record all statements made by the victim, regardless of its seeming pertinence to his or her medical care. Evidence that is improperly collected by untrained individuals, destroyed or mishandled during the course of treatment (e.g., contamination, using wound sites for drainage), or not followed in the chain of custody may be of limited value to law enforcement and justice officials.
The first step in preserving evidence is identifying the precise nature of the assault, circumstances, and scope of injury to the victim. This helps to determine the direction of the investigation and the type of forensic evidence to be obtained during the course of the clinical and forensic evaluation. The time of the assault and the sequence of events following should be ascertained, as the quality of evidence often deteriorates over time. For example, DNA in saliva deteriorates especially rapidly, often in less than 48 hours. It is recommended that a sexual assault forensic exam be administered within 96 hours of an attack for the collection of trace evidence; however, bruises, bite marks, and other injuries are often still evident beyond this time frame [16,17].
Any article or remnant of clothing worn by a victim or assailant at the time of the assault is considered important forensic evidence and should be preserved in transit. Each item should be placed in an individual evidence bag for forensic study by a law enforcement criminalist. An able patient needing to disrobe should do so over a drop sheet, which is then bound and labeled, in order to collect all traces of evidence. Upon arrival, whether by car or ambulance, the attempt should be made to locate all items of clothing. Emergency transport personnel should be able to account for this, but in their absence, the forensic team should identify and arrange to retrieve any relevant articles of clothing. Any tears or cuts to clothing made during treatment should be documented. Clothing removed in the ED must be recovered. If patients have changed clothing, the fresh clothing nearest the attack site (generally underwear or other undergarments) should be collected and examined as evidence.
Care should be taken to assure that the patient's skin remains unwashed until after examination and evidence collection is completed, because the skin often holds much of the most vital evidence for medical-forensic purposes. Contamination of evidence and swab specimens can be avoided by wearing appropriate protective equipment, handling as little as possible, and avoiding sneezing and/or coughing over samples. Forensic examiners should wear surgical masks during evidence collection, and gloves should be changed frequently.
In cases of food, beverage, and drug poisoning or tampering, vomitus is considered evidence and should not be discarded. In fact, whenever a forensic patient is vomiting, a sample should be collected and retained to determine if he or she has been the victim of poisoning. In certain instances, stool and urine samples should also be collected.
In the case of sexual assault, a determination should be made as to whether the assault has been reported to the police and whether representatives of law enforcement have already initiated an evaluation. If not, healthcare professionals have the duty to report cases of assault/abuse to officials. If law enforcement has already been involved, certain questions that could cause undue stress may be avoided during the examination (e.g., a description of the suspect); however, certain questions that pertain to the medical-forensic exam should be addressed. Questions that will have been asked by investigators include :
When the attack occurred (date and time)
Where the attack occurred and how it was initiated
What the suspect(s) said during the attack (e.g., threats)
Whether any items were stolen after the attack
How many individuals were involved in the attack
Description of the suspect(s), including age, height, weight, race, tattoos, scars, and other defects
If alcohol or drug use (or suspected "drugging") occurred before, during, or after the attack
How the patient was restrained during the attack (e.g., rope, belt, hands, feet)
Use of weapons by suspect
Use of powders, lubricants, or other chemicals during the attack
Means (e.g., penis, fingers, sex toys, other objects) and areas (e.g., mouth, vagina, anus) of penetration and/or contact
All injuries sustained during the attack (e.g., hitting, kicking, biting, spitting)
Questions pertaining to the medical-forensic exam include the last six on this list, as these serve to focus the physical exam and the search for evidence. If ejaculation took place, this location should be identified; however, other fluids, such as blood and saliva, are also useful for DNA collection. If there were multiple assailants, the patient should be encouraged to identify which assailant committed which act(s). The account should include all violence performed and/or threatened and should conclude by asking if there were any other acts performed that were not already covered.
Recent consensual sexual activity should be identified, along with information about what the patient did after the attack. Many women wipe their vulva with towels or toilet paper, and some may douche; this information should be noted so these items can be recovered for DNA testing. Tampons removed or inserted post-assault should also be recovered.
Sexual assaults are particularly difficult to discuss, but it is necessary to systematically explore several lines of questioning in order to assure a complete and accurate description of the assault. This will greatly aid both the collection of forensic evidence and the eventual prosecution of the suspect(s) for each violation. For example, an assailant can be convicted of attempted sodomy even if the act did not result in actual penetration. Therefore, a comprehensive list of possible sexual/violent acts should be discussed, each with its own specific question. There are four possible answers to every question: yes, no, attempted, and unsure . Sample questions would read as follows:
"Did the suspect put his/her finger(s) in your mouth?"
"Did the suspect put an object in your mouth?"
"Did the suspect put his penis in your mouth?"
"Did the suspect put his/her finger(s) in your mouth?"
"Did the suspect put his/her finger(s) in your vagina?"
"Did the suspect put his/her finger(s) in your anus?"
This line of questioning should continue until a very detailed description of the assault is documented; many jurisdictions use a locally standardized form for this task. It is important to remember that informed, written, and signed consent by the patient (or parent/legal guardian, where applicable) is required for a formal forensic evaluation. A provision for consent may be included in the forensic report paperwork. The U.S. Department of Defense Sexual Assault Forensic Examination Report is a good example of a federally standardized, complete form that incorporates a consent provision. It may be accessed online at http://www.sapr.mil/public/docs/miscellaneous/toolkit/dd_form_2911.pdf .
Examination of the patient should be conducted in a thorough head-to-toe manner, with the intent of documenting every indication of injury related to the incident (no matter how insignificant and involving every part of the body) using a body-map or wound chart. The entire body surface should be inspected and palpitated to identify areas of bruising and injury to muscle and bone. As evidence is detected during the course of the examination, it should be collected, documented, and preserved . Information gathered from transport personnel and during the forensic interview helps to identify areas requiring careful attention, but this should not detract from conducting a thorough examination.
An important component of the physical examination/interview is the patient's general appearance and demeanor upon presentation . This should be recorded as objectively and with as much description as possible in a few sentences. The ability of the patient to remember details of the incident and to cooperate with the exam should be noted.
The surface of the skin is usually examined first in cases of sexual assault. Those regions identified by history of the attack should be inspected first in good ambient light and then examined with an ultraviolet Wood's lamp to help visualize dried semen. Areas of fluid should be photo-documented and then swabbed completely until all material is removed from the skin . All regions of the body surface should be inspected for fluids. Control swabs should be taken from areas of the patient's skin not containing visible or fluorescent stains. Foreign hairs and fibers should be collected, and reference hairs should be selected for culling. Fingernail scrapings or cuttings should also be collected.
The examiner should then move to the oral cavity and inspect carefully for injury from forced entry, a hand or gag over the mouth, or other insult. Two swabs each are usually taken from the tongue, the tonsilar fossae, behind the buccal sulci, and behind the upper incisors when indicated by forcible oral copulation (or its attempt) or uncertain patient history (e.g., if the patient was drugged) .
The examiner should also be alert for bite marks. In sexual assault cases, these are seen most commonly on the arms, breasts, and thighs. Bite marks are particularly useful for perpetrator identification (i.e., bite mark matching) and for saliva collection, both of which can be used to link the victim to the suspect (self-defense biting) or the suspect to the victim (attack biting). Whenever possible, bite injuries should be examined by a forensic odontologist.
Bite marks should be very thoroughly photo-documented using an American Board of Forensic Odontology (ABFO) No. 2 scale. The location, size, shape, color, depth, and any other characteristics should be recorded. The area of the bite mark should then be double-swabbed for saliva, first using a swab wetted with distilled water and then immediately with a dry swab on the same area. The collection procedure involves rolling the swab while moving it in a circular pattern for 10 seconds . Both swabs should be air dried for at least 30 minutes or placed in a drier unit. The samples can then be sent for polymerase chain reaction amplification within 6 hours of collection if the swabs are kept at room temperature. The samples should be refrigerated (not frozen) if this time frame is not realistic.
The genital and perianal area should be examined thoroughly. As with the recovery of clothing, a drop sheet should be placed underneath the patient (separate from the clean paper sheet covering the table) to collect evidence that falls during the exam. The patient's pubic hair should be combed after the other steps are completed, and the drop sheet should be folded and labeled with pertinent information for later inspection by the criminalistics laboratory.
Crusted secretions or other attached material should be clipped out of the pubic hair and placed into evidence. Approximately 20 to 30 samples of the patient's own pubic hair should be plucked and kept separate as a control. A Wood's lamp should be used in the collection of semen samples from the external genital area, and enough swabs should be used to completely remove all visible traces. Following collection, a magnification device should be employed to further examine the area for micro-trauma. A gynecological colposcope is useful for this purpose as it provides sufficient lighting, magnification, and photographic capability .
The labia minora, posterior fourchette, and fossa navicularis typically sustain the most injury during an assault involving penile penetration only, while assaults involving digital penetration cause damage to the aforementioned sites and the vaginal walls, the cervix, and perineum (due to fingernails). Speculum examination of the vagina and cervix should be performed using only water as a lubricant. Where available, the use of colposcopy will facilitate the identification of trauma to these deep tissues. Though trauma from penile penetration alone is uncommon in women of childbearing age, significant vaginal or cervical trauma may be caused by penetration with objects . Adolescent and postmenopausal women typically sustain more damage during sexual assaults than others. Any items found inside the vagina should be removed and placed into evidence bags. Next, four swabs should be placed in the posterior fornix to absorb secretions. A dry mount and wet mount slide should be prepared from two swabs, while the remaining two are placed into evidence . The wet mount slide should be viewed within 10 minutes to identify motile sperm, and the slide examiner's name should be documented.
The perineum and anus should always be examined for trauma. If the patient is uncertain of anal penetration, if there was anal penetration with a foreign object, or if there is any bleeding or pain, the rectum should be examined with an anoscope and swabbed as per the technique discussed for vaginal swabbing. Secretions present on the anus are not considered conclusive evidence of anal penetration, as fluids may have leaked from the vagina.
Evidence collection kits may be created from materials on hand or may be obtained as prepackaged units. Either type functions effectively if it contains all the items necessary for evidence collection and documentation and includes a sturdy box for transportation and storage. Collection kits are not standardized on a state or federal level but should be on a jurisdictional basis. Every hospital should have a standard forensic protocol developed in accordance with, or in union with, the jurisdictional crime lab that must be followed in all forensic cases.
Forensic documentation includes a written component, a diagrammatic component, and a photographic component. Each should accurately inform the other. The written component should be detailed, accurate, and objective; the diagrammatic component should be thorough and legible; and the photographic component should include a measurement scale, be representative of the evidence, and remain objective.
In many cases of abuse and assault, the body is the only "crime scene." It is the duty of the medical-forensic examiner to accurately and diligently record the details of the injuries and the evidence present on the victim and/or perpetrator. The somewhat special skills once required by a forensic photographer shooting with a roll-film camera have been superseded by the widespread use of digital photography. Digital documentation simplifies many aspects of forensics, including ease of use, the number of images that can be recorded at very low cost, ability to review images and reshoot if needed, better control of the evidence chain of custody, and later ease of distribution during legal proceedings.
Photo-documentation will typically proceed along with the physical examination and the collection of evidence. When an injury or other evidence (e.g., fluids, fibers) is found, it should be photographed. It is considered good practice to capture four images of each finding . One should be an overall shot of the body and should include a clear anatomical reference (e.g., arm, hand, leg, foot), another should be a medium shot, and there should be two detailed shots of the finding. The wide and medium shots can be used to document multiple findings. Detailed shots of each finding should be taken before evidence collection, during manipulation, and after the evidence is swabbed or removed. If a lifesaving measure may disturb evidence, it is ideal to photograph the site/finding beforehand, if possible.
A measurement scale, such as the ABFO No. 2 scale, should be included in the two detailed shots. The finding should appear in the center of the frame, should be shot straight on (i.e., the body surface plane and the camera plane should be parallel), and the background should be as neutral as possible.
Assault victims are at risk for STIs, including chlamydia, gonorrhea, syphilis, hepatitis B, and human immunodeficiency virus (HIV). In general, the risk of infection is low, but it does vary directly in relation to the degree of genital trauma, associated bleeding (sustained by the victim or assailant), and the number of assailants. The estimated risk for acquiring an infection is 3% to 16% for chlamydia, 7% for trichomoniasis, and 11% for pelvic inflammatory disease . The Centers for Disease Control and Prevention (CDC) has published guidelines for the assessment, counseling, and preventive treatment of infection following sexual assault, including common pelvic infections, hepatitis B, and HIV .
Although HIV transmission after sexual assault has been reported, there are no epidemiologic data upon which to estimate risk from assault by an unknown assailant. In the context of consensual sex, the risk following a single exposure (vaginal intercourse) is estimated to be 0.1% . While the overall risk of acquiring HIV after a rape event is likely to be low, this risk may be substantially greater under certain circumstances, including:
Assaults occurring in geographic locales where the background prevalence of HIV is relatively high
Either the victim or assailant has open genital lesions and/or traumatic bleeding
Anal penetration and male-on-male rape
Testing for STIs during the acute evaluation phase is of limited value and may be deferred until later. In selected cases, the decision to administer antimicrobial prophylaxis may obviate the need for testing. Table 1 provides a suggested approach to testing, derived from the CDC's 2010 guidelines . The initial examination includes testing of cervical/vaginal secretions for chlamydia and gonorrhea by nucleic acid amplification test (NAAT) and for trichomoniasis by vaginal swab wet mount examination. Serum serologic testing for hepatitis B, syphilis, and HIV should also be considered.
TESTING FOR STIs AFTER SEXUAL ASSAULT
|Initial Examination||Follow-Up Examination (Within 1 to 2 Weeks)|
The CDC recommends HIV screening of sexual assault patients after the patient has been informed and unless the patient declines . Some states stipulate that HIV testing must be coupled with mandatory counseling and follow-up care. The policy and guidelines should be worked out in advance within each locale and jurisdiction, in accordance with prevailing law and established guidelines.
Testing for HIV in the immediate post-assault period has limited utility, as it will not confirm or exclude exposure, nor will it indicate whether the victim is likely to become infected . For purposes of later criminal or civil action, the patient may wish to have baseline testing to demonstrate absence of prior infection. Thus, the option for confidential, anonymous baseline testing should be offered and discussed.
Empiric prophylactic antimicrobial treatment is recommended for all patients following the initial evaluation, in part because most patients want this and in part because of uncertainty regarding when and where the patient will be followed. The CDC has established guideline recommendations for drug prophylaxis to prevent gonorrhea, chlamydia, and trichomoniasis infection (Table 2) :
Gonorrhea: Ceftriaxone, 250 mg IM, in combination with azithromycin, 1 gram PO (single dose), or doxycycline, 100 mg twice daily for seven days
Chlamydia: Either azithromycin, 1 gram PO (single dose), or doxycycline, 100 mg PO twice daily for seven days. Avoid doxycycline in pregnant women and in children younger than 8 years of age.
Trichomoniasis: Metronidazole, 2 grams PO (single dose)
DRUG PROPHYLAXIS AFTER SEXUAL ASSAULT
|Pregnancy||Levonorgestrel, 1.5 mg orally (single dose), preferably given within 12 hours of exposure if urine and/or serum pregnancy test is negative|
|Sexually transmitted infections|
|Gonorrhea, chlamydia, and trichomoniasis||Ceftriaxone, 250 mg IM, plus azithromycin (1 g orally in a single dose) or doxycycline (100 mg twice daily for 7 days), plus metronidazole, 2 g orally (single dose)|
|Hepatitis B||Vaccination protocol (unless known to be immune)|
|HIV||HIV combination antiviral therapy, 28-day course, initiated within 72 hours of exposure. The decision to treat (based on risk assessment) and the choice of drug regimen should be made in consultation with local infectious disease specialists|
Because of decreasing susceptibility to oral cephalosporins among isolates of Neisseria gonorrhoeae, the CDC amended its recommendations in 2012, omitting the option of oral cefixime for the treatment of gonococcal infection.
If the latent infection status of the assailant is unknown, routine postexposure hepatitis B vaccination is adequate, without the need for specific immune globulin (HBIG). If the assailant is known to be hepatitis B positive, HBIG should be added. Follow-up doses of vaccine are recommended at 1 to 2 and 5 to 6 months after the first dose .
Despite the low risk of HIV transmission, most clinicians and other healthcare professionals who specialize in the care of sexual assault patients believe that postexposure prophylaxis (PEP) should be offered in nearly all cases. The CDC guidelines recommend a 28-day course of highly active antiretroviral therapy (HAART), initiated within 72 hours of exposure . Available data indicate that the effectiveness of HAART falls off if initiated beyond 72 hours of exposure, at which point the risk/benefit ratio begins to favor omitting PEP. Thus, antiretroviral therapy should be started as soon as possible after the assault, ideally within 4 hours, and probably should not be initiated if greater than 72 hours have elapsed. It is recommended that the decision and choice of antiviral therapy be made in consultation with an infectious disease specialist or other healthcare professional familiar with the most current PEP guidelines.
The risk of becoming pregnant after vaginal rape is estimated to be 5% . It is generally recommended that rape victims of childbearing age have a baseline urine or serum pregnancy test performed, in anticipation of offering prophylaxis against pregnancy if the result is negative.
Postexposure emergency contraceptive treatment options are available for preventing pregnancy after unwanted intercourse . The simplest and best-studied product is levonorgestrel (Plan B), an oral progestin-only medication developed for this purpose. The dosage regimen is 1.5 mg (two 0.75-mg tablets) administered as a single oral dose. It is considered to be most effective when administered within 12 hours of the assault. In one carefully conducted study, the success rate (prevention of pregnancy) exceeded 95% when administered up to 120 hours after unprotected intercourse . This medication is safe and well tolerated, even if given to someone who is pregnant. Systemic side effects, such as headache, nausea, fatigue, and gastrointestinal/abdominal complaints, occur in less than 10% of patients. Transient vaginal bleeding in the days following treatment is more common (25% to 30%).
Clinical care providers should be alert for, and responsive to, the emotional trauma sustained by the sexual assault victim. In the hours following an assault, these patients exhibit a range of emotional responses, including fear, panic, shame, anger, mistrust, and denial. They are in need of emotional support, comfort, and the assurance of protection. Often, there is a need for reassurance that the victim is not at fault, no matter the circumstances surrounding the assault. Rape crisis counseling and social services should be enlisted early to assist in the care of the patient and to develop a discharge plan that addresses emotional needs, support systems, safely issues, and follow-up care.
The patient should be seen in follow-up within one to two weeks. The purpose of this encounter is to assess clinical progress and compliance with medication, to check the adequacy of the patient's support system, and to offer counseling. A diagnostic evaluation for STIs may be performed as well, if this was deferred at the time of the initial evaluation.
Additional medical follow-up is indicated at six weeks, three months, and six months for repeat serologic testing (e.g., syphilis, HIV) and to complete the hepatitis B vaccination protocol.
In the aftermath of sexual assault, a variety of chronic somatic, cognitive, and emotional sequelae have been observed in sexual assault victims (Table 3). The individual's response and subsequent ability to cope with the trauma of the assault are influenced by a number of related factors. These include the nature and severity of the assault itself, age of the victim, relationship between the victim and assailant, prior history of abuse, and the person's own ambient life stress and coping mechanisms. For some, the impact of a sexual assault experience is severe and long-lasting, often resulting in difficulty with interpersonal relationships and tasks of daily living, sexual dysfunction, loss of work-time, and increased utilization of healthcare resources [25,26,27].
LONG-TERM PHYSICAL AND EMOTIONAL IMPACT OF SEXUAL ASSAULT
|Chronic Somatic Disorders||Psychosocial Disorders|
A meta-analysis of clinical studies published between 1980 and 2002 revealed a significant association between prior sexual assault and the lifetime diagnosis of fibromyalgia, chronic pelvic pain, and functional gastrointestinal disorders . In a cross-sectional, randomly selected study of 219 women followed in a Veterans Administration (VA) primary care clinic, a history of prior sexual assault was found to be associated with a significant increase in somatization scores, multisystem physical complaints, anxiety, work absenteeism, and health care utilization . Among another cohort of women receiving VA medical and mental health care, the prevalence of post-traumatic stress disorder was found to be 7 to 9 times higher in women who had experienced a prior sexual assault, compared with those having no assault history .
To summarize, the priorities of acute care counseling are to provide emotional support, assure a plan for patient safety, and assess coping skills and strength of support system post-discharge. When possible, arrangements should be made for ongoing counseling through sexual assault crisis programs. In anticipation of the long-term adverse effects of sexual assault, arrangements should be made for primary care follow-up and patients and families should be offered information and access to mental health services.
|Office on Violence Against Women National Protocol for Sexual Assault Medical Forensic Examinations|
|American College of Emergency Physicians Management of the Patient with the Complaint of Sexual Assault|
|Sexual Assault Forensic Examiner Technical Assistance|
|International Association of Forensic Nurses|
|Centers for Disease Control and Prevention|
|Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55:1-17.|
1. Tjaden P, Thoennes N. Extent, Nature, and Consequences of Rape Victimization: Findings from the National Violence Against Women Survey. Available at https://www.ncjrs.gov/pdffiles1/nij/210346.pdf. Last accessed September 11, 2014.
3. Krebs CP, Lindquist CH, Warner TD, Fisher BS, Martin SL. College women's experiences with physically forced, alcohol- or other drug-enabled, and drug-facilitated sexual assault before and since entering college. J Am Coll Health. 2009;57(6): 639-647.
4. Balsam KF, Rothblum ED, Beauchaine TP. Victimization over the life span: a comparison of lesbian, gay, bisexual, and heterosexual siblings. J Consult Clin Psychol. 2005;73:477-487.
5. Lawyer, S, Resnick H, Bakanie V, Burkett T, Kilpatrick D. Forcible, drug-facilitated, and incapacitated rape and sexual assault among undergraduate women. J Am Coll Health. 2010;58:453-460.
6. Campus Sexual Assault (CSA) Study. Final Report Submitted to the National Institute of Justice. Available at https://www.ncjrs.gov/pdffiles1/nij/grants/221153.pdf. Last accessed September 10, 2014.
7. Riggs N, Houry D, Long G, Markovchick V, Feldhaus, KM. Analysis of 1,076 cases of sexual assault. Ann Emerg Med. 2000;35(4):358-362.
8. Avengo A, Mills T, Mills L. Sexual assault victimization in the emergency department: analysis by demographic and event characteristics. J Emerg Med. 2009;37(3): 328-334.
9. Slaughter L, Brown C, Crowley S, Peck R. Patterns of genital Injury in female sexual assault victims. Am J Obst Gynecol. 1997;176(3):609-616.
10. Holmes, M. Resnick H. Kilpatrick, D, et al. Rape-related pregnancy estimates and descriptive characteristics from a national sample of women. Am J Obstet Gynecol. 1996;175(2): 320-324.
11. U.S. Department of Justice, Office of Violence Against Women. A National Protocol for Sexual Assault Medical Forensic Evaluations Adults/Adolescents. Available at https://www.ncjrs.gov/pdffiles1/ovw/241903.pdf. Last accessed September 11, 2014.
12. Burgess A, Fawcett J. The comprehensive sexual assault assessment tool. Nurse Pract. 1996;21(4):66, 71-76, 78.
13. Maguire W, Goodall E, Moore T. Injury in adult female sexual assault complaints and related factors. Eur J Obstet Gynecol Reprod Biol. 2009;142:149-153.
14. Machielse P. Forensic Emergency Nursing: Role Integration. Available at http://www.iafn.org/displaycommon.cfm?an=1&subarticlenbr=249. Last accessed September 11, 2014.
15. Riviello R. Manual of Forensic Emergency Medicine. Sudbury, MA: Jones and Bartlett Publishers; 2010.
16. Texas Attorney General. Sexual Assault Nurse Examiner (SANE) Program: Frequently Asked Questions. Available at https://www.texasattorneygeneral.gov/faq/cvs-sexual-assault-nurse-examiner-sane-program-frequently-asked-questions. Last accessed July 23, 2015.
17. New York University Student Health Center. Sexual Assault Prevention and Response. Available at http://www.nyu.edu/life/safety-health-wellness/wellness-exchange/sexual-assault-prevention-and-response.html. Last accessed September 11, 2014.
18. Hammer R, Moynihan B, Pagliaro EM. Forensic Nursing: A Handbook for Practice. Sudbury, MA: Jones and Bartlett Publishers; 2006.
19. U.S. Department of Defense. DoD Sexual Assault Forensic Examination Report. Available at http://www.sapr.mil/public/docs/miscellaneous/toolkit/dd_form_2911.pdf. Last accessed July 23, 2015.
20. Glaser JB, Schachter CM, Benes S, et al. Sexually transmitted infection in postpubertal female rape victims. J Infect Dis. 1991;164(4):726-730.
21. Workowski KA, Berman S. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR12):1-110.
22. Gostin LO, Lazzarini Z, Alexander D, Brandt AM, Mayer KH, Silverman DC. HIV testing, counseling, and prophylaxis after sexual assault. JAMA. 1994;271(18):1436-1444.
23. Stewart FH, Tressell J. Prevention of pregnancy resulting from rape: a neglected preventive public health measure. Am J Prev Med. 2000;19(4):228-229.
24. Von Hertzen H, Piaggio G, Ding H. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicenter randomized trial. Lancet. 2002;360:1803-1810.
25. Schwartz J. Sexual violence against women: prevalence, consequences, societal factors, and prevention. Am J Prev Med. 1991;7(6):363-373.
26. Goodman LA, Koss MP, Russo NP. Violence against women: physical and mental health effects. Part 1: research findings. Applied and Prev Psychol. 1993;2(2):79-89.
27. Ahrens C, Aldana E. The ties that bind: understanding the impact of sexual assault disclosure on survivors' relationships with friends, family, and partners. J Trauma Dissociation. 2012;13(2):226-243.
28. Paras M, Murad M, Chen L, et al. Sexual abuse and lifetime diagnosis of somatic disorders: a systematic review and meta-analysis. JAMA. 2009;302(5):550-561.
29. Stein M, Lang A, Laffaye C, Satz L, Lenox R, Dresselhaus T. Relationship of sexual assault history to somatic symptoms and health anxiety in women. Gen Hosp Psychiatry. 2004;26(3):178-183.
1. Centers for Disease Control and Prevention. Sexual assault and STDs. In: Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR12):90-95. Summary retrieved from National Guideline Clearinghouse at http://www.guideline.gov/content.aspx?id=25597. Last accessed September 12, 2014.
Mention of commercial products does not indicate endorsement.