Sexual Assault History and Physical

Article Author:
Carolyn Sachs
Article Editor:
Jennifer Chapman
Updated:
6/18/2019 4:43:28 AM
PubMed Link:
Sexual Assault History and Physical

Introduction

A practitioner must conduct a compassionate, complete history and physical examination of adult men or women after sexual assault. The complex nexus between a physician caring for a patient and police requests for evidence must be addressed with the patient before collection. Each examination must be tailored to the specific circumstances reported by the patient rather than a one-protocol-fits-all approach. [1]

Sexual assault is defined as sexual contact between individuals without appropriate legal consent. Rape is one form of sexual assault involving penetration, however slight, of the vaginal or anal opening. Though physical force may be used, sexual assault includes coercion into sexual contact by intimidation, threats, or fear. Local laws variably define the exact acts that constitute sexual contact and the specific populations unable to give legal consent. In general, those under the influence of drugs or alcohol, minors, and developmentally delayed individuals may be considered unable to give consent for sexual contact.[2]

Function

Patients who are sexually assaulted may present directly to medical providers for treatment or present accompanied by law enforcement personnel. Medical professionals must provide compassionate and confidential treatment in a timely fashion. Psychosocial support begins with the first patient contact. All medical providers with subsequent contact need to use sensitivity and maintain patient confidentiality. Prior arrangements should be made with local sexual assault crisis centers and social work facilities to provide immediate support and assistance with the evaluation procedure.[3]

A family member or a friend may accompany a victim. In most cases, allow this person to stay with the victim in accordance with his or her wishes. Additionally, if a victim presents alone, medical providers should offer her the chance to call a companion and/or a crisis advocate to accompany him or her during the evaluation.

Providers must address and treat any life-threatening or limb-threatening physical injury and assess for suicidality. A minority of sexually assaulted patients require such immediate intervention, but in the rare case of coexistent severe trauma, providers should be careful to preserve evidence on the patient’s body if possible by using gloves and avoiding washing off areas that may have potential secretions. Some states mandate that providers contact law enforcement for patients reporting sexual assault. Providers must know local laws governing such reporting. Even when states mandate reporting, federal United States law permits all patients to undergo a forensic examination without charge. Patients undergoing forensic examination are not required to discuss the event with police.

The history must be taken in a private room using a compassionate tone to explain the steps of a forensic evaluation. Providers must obtain written informed consent for the examination and forensic evaluation prior to the history and physical. Obtaining consent carries important psychological implications after a sexual assault in which a victim’s consent right was violated. Forms that require information about gender or sex should allow for victims to write a response that may not be listed as an option. Sexual assault examination teams should be involved as early as possible if available. Many institutions in the United States arrange to utilize sexual assault nurse examiner (SANE) programs, which provide highly specialized treatment for sexual assault victims.[4]

Unlike many histories in traditional medical evaluations, more is not better when exploring the history of a sexual assault. Providers should take an appropriately tailored history rather than an exhaustive account of the details of the encounter. Recounting the details of a sexual assault may traumatize victims, so the need for assault details should be balanced with sensitivity to the patient’s emotional needs. An appropriate history includes information necessary for medical treatment, completion of standardized forensic legal forms, and the collection of evidence. Historical assault information may be important when trying to correlate physical findings or corroborating evidence. The table below describes historical elements that documentation forms often contain. However, due to assault-induced distress and/or drug-facilitated sexual assault, victims commonly cannot answer all the questions. It is perfectly acceptable to use the “unknown” response when completing legal forms. [5]

In addition to the standard gynecological history, if a patient uses an oral contraceptive, providers should query about missed doses. This information will assist in deciding administration of post-coital contractive medical treatment (see section on emergency contraception).

Issues of Concern

Before beginning the physical examination, remind a patient that he or she is in control of every element of the examination and may refuse at any point. Physical examination goals include the determination of medical treatment needs, collections of specimens for crime lab analysis, and documentation of injury findings. Patients should undress over a clean sheet or paper, dropping the clothes if collecting them for evidence (see later section on clothing evidence collection). Providers should perform a complete skin exam, noting any traumatic findings including but not limited to lacerations, abrasions, bruises, swelling, and bite marks. Make notations regarding areas that are tender as bruising may develop later and may be difficult to identify in patients with more pigmented skin. Examiners should note, photograph, and collect any debris, wet secretions, and crusted areas of dry secretions observed on the skin (see evidence collection). Part of most sexual assault includes an oral exam for injury making sure to look at both the buccal and gingival mucosa in addition to the usual medical, oral exam.[6]

Similarly, most sexual assaults involve non-consensual genital contact hence providers need to examine patient’s external genitalia for abrasions, lacerations, bruises, bleeding, areas of tenderness, and wet or dry secretions.

Documentation of injuries discovered on the physical exam should describe the body or genital location, bleeding, size, and color. Photography provides excellent documentation and is standard procedure for sexual assault examinations performed by sexual assault forensic examiners (SAFEs). A SAFE often uses toluidine blue dye to highlight injury when taking photographs (discussed in a separate area). Additionally, a SAFE employs a method to enhance identification of an injury, such as a macro lens on a digital camera or a free arm medical magnifier. Gentle separation of the labia and inferior traction may increase examiners ability to detect injuries to the perineum and hymen. In male victims, the penis and scrotum should be examined for injury.[7]

Providers should perform a speculum exam in female victims to look for injuries to the vaginal wall, cervix, or any foreign bodies if a patient can tolerate such an exam and has reported genital contact or was unconscious. Examiners will collect specimens from the external genitalia, vaginal vault, and cervix as described later in evidence collection. A bimanual examination is not a routine part of the sexual assault examination. Inspect the anal and peri-anal area for injury, swelling, and bleeding in all gender victims and perform anoscopy if the patient reports anal penetration, anal pain, anal bleeding, or has reported a loss of consciousness during the assault. Patients may display anal injuries during anoscopy even with a normal external anal exam and no complaints of pain. Anal and/or rectal swabs forensic collection should be done during anoscopy.[8]

Clinical Significance

Sexual assault may trigger severe depression and even suicidality. The practitioner’s history includes assessment for suicidality and, if found, immediate referral to a mental health professional. In most areas in the United States, rape crisis advocates can provide timely support to victims during the examination and throughout follow-up. Psychological and advocacy follow-up programs must be arranged. Survivors may suffer from rape trauma syndrome, which presents with a pattern of symptoms that are similar to posttraumatic stress disorder. The patients must plan to follow up approximately 1 to 2 weeks after the initial evaluation to determine the need for further counseling.[9]

The way a provider interacts with victims can make the difference in his or her ability to begin the path of recovery and healing.  The clinical significance of a kind and compassion patient-centered encounter is that of improved physical and mental well being during and after the encounter. Providers should keep this goal in mind throughout the history taking and physical examination.[10]


References

[1] Assessing the extent of provision of comprehensive medical care management for female sexual assault patients in US hospital emergency departments., Patel A,Roston A,Tilmon S,Stern L,Roston A,Patel D,Keith L,, International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics, 2013 Oct     [PubMed PMID: 23850033]
[2] Martin S,Housley C,Raup G, Determining competency in the sexually assaulted patient: a decision algorithm. Journal of forensic and legal medicine. 2010 Jul;     [PubMed PMID: 20569956]
[3] Factors That Influence Women to Disclose Sexual Assault History to Health Care Providers., Berry KM,Rutledge CM,, Journal of obstetric, gynecologic, and neonatal nursing : JOGNN, 2016 Jul-Aug     [PubMed PMID: 27238901]
[4] Campbell R,Bybee D,Townsend SM,Shaw J,Karim N,Markowitz J, The Impact of Sexual Assault Nurse Examiner Programs on Criminal Justice Case Outcomes: A Multisite Replication Study. Violence against women. 2014 May;     [PubMed PMID: 24875379]
[5] Evaluation and Treatment of the Adolescent Sexual Assault Patient., Mollen CJ,Goyal M,Lavelle J,Scribano P,, Adolescent medicine: state of the art reviews, 2015 Dec     [PubMed PMID: 27282016]
[6] Linden JA, Clinical practice. Care of the adult patient after sexual assault. The New England journal of medicine. 2011 Sep 1;     [PubMed PMID: 21879901]
[7] Genital injuries in adults., White C,, Best practice & research. Clinical obstetrics & gynaecology, 2013 Feb     [PubMed PMID: 23219384]
[8] Anogenital and Physical Injuries in Adolescent Sexual Assault Patients: The Role of Victim-Offender Relationship, Alcohol Use, and Memory Impairment., Feeney H,Chiaramonte D,Campbell R,Greeson MR,Fehler-Cabral G,, Journal of forensic nursing, 2017 Apr/Jun     [PubMed PMID: 28525429]
[9] McNally RJ,Bryant RA,Ehlers A, Does Early Psychological Intervention Promote Recovery From Posttraumatic Stress? Psychological science in the public interest : a journal of the American Psychological Society. 2003 Nov;     [PubMed PMID: 26151755]
[10] Eisenberg ME,Lust KA,Hannan PJ,Porta C, Campus Sexual Violence Resources and Emotional Health of College Women Who Have Experienced Sexual Assault. Violence and victims. 2016;     [PubMed PMID: 26822585]