The effects a sexual assault on a survivor can be profound and multifaceted. Some of the aftermath may include bodily and/or anal/genital injury, sexually transmitted infection (STI) or disease (STD), post-traumatic stress disorder (PTSD), depression, suicidal ideation, and pregnancy. There is no typical experience or survivor response. So, if a survivor presents to the Emergency Departments for care, it is imperative for healing that the response is stabilizing, coordinated, and compassionate. Immediate needs of a survivor of sexual assault include: medical and/or psychiatric evaluation and stabilization, activation of community advocacy to the bedside, mandated reporting as directed by state statutes, offering and conducting (if desired by the survivor) the Sexual Assault Forensic Exam (SAFE), collaboration with law enforcement (if desired by the survivor), prophylactic medications for STI and STD, pregnancy risk evaluation and care and safe discharge planning. Those providing medical and forensic care must always be prepared to provide testimony as either a fact and/or expert witness.
Sexual assault (SA) is defined as any type of sexual contact or behavior that occurs without the explicit consent of the recipient of the unwanted sexual activity. SA may also include psychological coercion or taking advantage of an individual who is under duress, incapacitated, or unable to make decisions. 1 A timely, high-quality medical forensic examination can potentially validate and address sexual assault patients’ concerns, minimize the trauma they may experience, and promote their healing. At the same time, it can increase the likelihood that evidence collected will aid in criminal case investigation, resulting in perpetrators being held accountable and further sexual violence prevented. 2
In April of 2013, the U.S. Department of Justice Office on Violence Against Women released the Second Edition of A National Protocol for Sexual Assault Medical Forensic Examinations for Adults and Adolescents which is not specific to jurisdictions but provides a comprehensive and victim centered approach. Best practice supports can be found on the www.SAFEta.org website including sample forms for the Consent for SAFE, Forensic Photography, and Notification/Activation of Law Enforcement, Sexual Assault Medical Forensic Examination Flowsheet, and Chain of Custody. This site is also provides resources and guidance for development of community Sexual Assault Response Team (SART) and Sexual Assault Nurse Examiner (SANE) Program Management.
Because sexual assault is one of the most invasive and intimate forms of violence, a Trauma Informed Care (TIC) approach should be utilized. TIC is an appreciation for the high prevalence of traumatic experiences in persons who receive services. It involves thorough understanding of the profound neurological, biological, psychological and social effects of trauma and violence on the individual. During traumatic experiences, stimuli are received into the body by the five senses. Retraumatization is a situation, attitude, interaction, or environment that replicates the events or dynamics of the original trauma and triggers the overwhelming feeling and reactions associated with them. In a SAFE exam, an examiner is literally going to every place on the body that has been traumatized and/or violated.
Trauma-Informed Care Philosophy outlines a kind of universal precautions. Care providers do not know what kinds of experience’s patients have had as they present for services, so we approach them in a universally sensitive manner to minimize retraumatization. Antidotes to Retraumatization are safety, trustworthiness, choice, collaboration, and empowerment. Table 1 1 outlines these antidotes and recommends concrete application of these TIC tools for most sensitive approach and practice. 5
Application of Trauma Informed Care to the Care of the Patient that Discloses Sexual Assault
| Safety | Knock on the door and ask permission to enter the patient’s room Meet with the person before they disrobe Ask the person to disrobe only when necessary or only partially disrobe Provide and clearly identify washrooms Take time to familiarize the person with the physical environment Ask about comfort level with lighting Share control Show respect Use a warm and compassionate manner to build rapport |
| Trustworthiness | Explain all procedures in terms the person can understand Tell the person what to expect and how long it will take Ask the person what he or she wants |
| Choice | Ask if you can touch them each time Ask before you invite in additional staff Ask if you can close the door Allow the person to decide where to sit in the room Explain rationale for each procedure. What the procedure will feel like and make appropriate modifications to reduce retraumatization Obtain consent for each part of the exam performed |
| Collaboration | Ask “What are your top worries or concerns” and address these first if possible Share information Encourage the person to make decisions about treatment |
| Empowerment | Ask “What happened to you,” not “What is wrong with you?” Never ask “Why” questions as they imply fault Take time with the person so he or she feels genuinely heard Ask if the person has preferences related to or has had difficulty with a particular procedure Ask the person what you should know before you begin the procedure Ask if there is a way you can make the procedure easier for the him or her Ask if there is a way you can make the person relax: like a different position Pay attention to body cues; many survivors have been conditioned to be passive and defer to authority and so may not disclose distress during a procedure |
Elements of the SA History *
| Medical History | Information pertinent to the interpretation of forensic findings e.g. recent injury, current menstruation, surgery on reproductive organs etc. |
| Recent Consensual Sexual Activity | To eliminate consensual partners as suspects, as there may be DNA or trace evidence remaining and/or injury unrelated to the assault. Date, time, location of penetration and ejaculation should be recorded for any/all consensual partners for 7 days prior to the sexual assault. |
| Assault-Related Medical History | Loss of consciousness, memory loss, pain, obvious injury, vomiting, etc. |
| Sexual Assault Details | Date and time of assault, position, sequence, ejaculation, use of lubricants and/or condoms, type of contact (genital and/or nongenital), penetration, use of objects |
| Nature of the Physical Assault | Verbal and nonverbal threats, use of weapons, degree of force used (restraints, physical blows, strangulation,) voluntary or involuntary ingestion of drugs and/or alcohol that were utilized to facilitate the assault. Any injury to perpetrator. Location of the SA including description of physical surroundings (e.g. couch, rug, grass, car, etc.) |
| Post Assault Activities | Time and certain actions that can destroy physical evidence (e.g. urination, defecation, vomiting, bathing, douching, removal or insertion of anything in the vaginal, rectal or oral cavity, brushing teeth, mouth wash, genital or body wipes, eating, drinking, smoking, use of drugs etc.) |
| Suspect Information | Limited information only such as number of suspects, age, race, relationship, sexual dysfunction, etc. (details will be obtained by law enforcement) |
When a patient presents and reports a sexual assault, triage the patient as a medical emergency (no less than a level 3 in a typical 5-tier emergency department triage system). Promptly place the patient in an available room. If a room is not available, place the patient in a secure and quiet area away from the waiting room. Obtain consent for medical evaluation and treatment per hospital policy. Immediately assess for and treat life-threatening conditions, serious injuries or psychiatric emergencies.
Use caution when treating injuries and/or assessing the patient to prevent destruction or contamination of potential evidence. For example, wear non-powdered gloves for physical contact, avoid IV attempts over wounds, avoid Foley catheter insertions or obtaining urine specimens, and avoid giving anything PO or PR unless necessary for medical stabilization. Instruct patient not to wash, change clothes, urinate, defecate, smoke, drink, or eat unless necessary to treat acute medical needs. If clothing must be removed, do not cut through existing tears or stains. Activate bedside advocacy and Social Work Services if indicated to assist with mandated reporting. (e.g. patient is a minor, elderly, incapacitated, or if other concerns arise). 2
Assess the patient’s communication needs and provide support services and assistive devices according to hospital policy, including interpreter services if applicable. Identify patients with disabilities; assess their ability to consent to treatment and SAFE exam, and contact parent/guardian if indicated. Hold narcotic and other mind altering medications unless medically necessary, until informed consent has been obtained for the exam.
A patient should be informed that although written consent is obtained, he or she can decline any part of the exam for any reason. The reason for declining a portion of the exam should be documented using direct quotes from the patient.
The SAFEta website has forms that can be adapted to hospital protocol or utilized “as is” for obtaining the medical forensic history of an assault. The Department of Health and Senior Services (DHSS) also has forms that can be downloaded at the www.dhss.mo.gov website. Both of these forms contain body maps for documenting injury and debris. These medical forensic records should be kept separate from the hospital medical record to be compliant with guidelines set forth by The Violence Against Women Act (VAWA).
Questions regarding the forensic history should be asked least invasive to most invasive. Re-telling of events may cause re-traumatization. So, whenever possible, forensic history should be obtained with advocacy and law enforcement to minimize the number of times the patient discloses events and to ensure proper emotional support. Language consistent with the experience should be considered. For instance, instead of asking, did you perform oral sex? Ask, ‘did he force his penis into your mouth?’ Answers to these questions will guide evidence collection. A narrative of the events of the assault should include date, time, location(s) and description of the assault in the patient’s own words using quotations. If a slang term or nickname is used to describe the events or body parts, these should be clarified by the examiner.
Each jurisdiction has a designated sexual assault evidence kit with specific directions for collection as requested by the crime lab that will be analyzing specimens. Examiners are encouraged to collaborate with the crime lab to ensure proper evidence is collected, preserved, and packaged according to preferences. Exams and order of evidence collection can always be altered to fit the emotional needs of the patient. Deviation from the requested order of collection should be documented and a reason provided. Many crime labs request smears on microscopic slides from any area with suspected semen which may include oral, vaginal, cervical, anal, rectal, penile, and areas of positive wood’s lamp illumination. These should be collected and submitted according to the assault history and examination. (See Figures 1 and and2 2 .)
1 Erythema (redness)
Tenderness–noted laceration vestibule and labia minora between 10 and 11 o’clock active bleeding noted
2 Erythema (redness)
Tenderness - noted laceration at 12 o’clock from clitoral area to vestibule. Active bleeding noted.
3 Erythema (redness)
Tenderness - noted laceration between 1 and 2 o’clock vestibule. Active bleeding noted.
4 Erythema (redness)
Tenderness - noted laceration at 1 o’clock in vestibule. Active bleeding noted.
* 1.5 hours post assault
Tenderness from the fossa navicularis to the posterior fourchette between 7 and 6 o‘clock
Tenderness - noted on the left labia minora at 5 o’clock
Tenderness - noted on left labia minora between 4 and 5 o’clock
Tenderness laceration between 4 and 5 o’clock left labia majora
*7.3 hours post assault
During and immediately following a SAFE exam, the evidence will be packaged and sealed by the examiner who will maintain chain of custody. Examiners should be aware of the crime lab’s requirements on collection, packaging, labeling, storage, handling, transportation, and delivery of specimens. The examiner must remain with the evidence at all times until it is secured in designated locked area or retrieved by a law enforcement officer. 2 Examples of Chain of Custody forms can be found on the SAFEta website.
A Drug Facilitated Sexual Assault (DFSA) is when a person is subjected to sexual act while they are incapacitated or unconscious due to the effects of alcohol and/or drugs that have been taken voluntarily or involuntarily. The pharmacological effects of the drugs prevent the person from consenting or resisting. First responders must recognize that although Rohypnol and gamma hydroxy butyrate (GHB) are widely publicized as the “drugs of choice” in drug-facilitated sexual assault, assailants may use numerous other substances (including alcohol) to facilitate sexual assault. They must understand the urgency of collecting toxicology samples, if it is medically necessary, or if an alcohol- or drug-facilitated sexual assault is suspected, as well as the importance of obtaining informed consent from patients prior to sample collection. They should also be aware that collection of toxicology samples is typically separate from the sexual assault forensic evidence collection kit, and procedures for toxicology analysis may be different from that of other evidence analysis. Ideally, the first available urine sample should be collected in suspected alcohol- or drug-facilitated sexual assault cases. 2
The examiner should carefully document signs and symptoms post assault. Documentation should include both objective and subjective findings either reported by the patient or witnesses which can include hospital staff. Signs and symptoms may include but are not limited to: vital signs, pupil dilatation, accommodation, and reaction with light, presence of vertical or horizontal gaze nystagmus, nauseas/vomiting/diarrhea, headache, dizziness, weakness, seizures, loss of inhibitions, hallucinations, and/or dissociation. It is particularly important to record the time and date of the known or suspected ingestion with the type, brand, or amount of substance and the number of times the patient has voided prior to the urine collection.
Additional evidence collection should be consistent with what the patient is able to recall about the assault. Often with DFSA, the patient will report memory loss or confusion surrounding events. Most crime labs have developed a protocol for collection of specimens from “high yield areas” to help guide collection in situations of memory loss or confusion. This protocol can be applied to all patients that report memory loss due to blunt trauma or altered mental status related to illness or disease process as well.
In cases of sexual assault, all patients are offered prophylactic medication to prevent gonorrhea and chlamydia infection given the high rates of infection after assault. Trichomoniasis and bacterial vaginosis can be diagnosed or excluded in the emergency department if microscopy is available; other wise empiric treatment should be administered. Routine testing for gonorrhea, chlamydia, and syphilis is not recommended at the initial exam in the setting of sexual assault because results of that testing would determine whether the patient had an STI prior to the assault. This information can be used to bias a jury against a victim in court. 6 Table 3 has the CDC recommended STD/STI and Pregnancy Prophylaxis and Follow-up.
Recommended STD and Pregnancy Prophylaxis and Follow-up
