LECTURE SCRIPT

SEXUAL ASSAULT
Captain Joseph R. Hoffman, MD, US Army
Madigan Army Medical Center
Ft. Lewis, Washington


Sexual assault is one the fastest-growing violent crimes in the United States. The Department of Justice reported the annual incidence of sexual assault was 80 per 100,000 women in 1990. This accounts for 7 percent of all violent crimes in America.(1) The typical age for the sexual assault victim is between the ages of 15 to 26 years, and the majority of these will be single, divorced, or separated. Over half of the victims know their assailants.(2) A second incidence peak has been noted in women over 50 years of age. (3)

The sexual assault examination is intrusive and for some victims as demoralizing as the assault itself. As desirable as it would be to expedite these individuals through their ordeal, it must not be overlooked that they may victims of potentially life-threatening trauma. Among assaulted women, 0.1 percent sustained fatal injuries with asphyxiation leading the list. (4)

This is a preview of the lecture and we cover all these topics.

Emergency physicians have out of circumstances and necessity become the experts in the sexual assault exam. In the discussion to follow, the primary focus will be on the adult victim. The topic of pediatric sexual assault is a treatise in itself. While in this discussion, the victim may be referred to as "female", the victim may of course be male. Moreover, the forensic exam discussed below is more commonly performed on victims, the same samples can and are collected from suspected assailants. For the victim, the examining physician has both medical and legal duties. The physician must obtain a history, evaluate and treat physical injuries, obtain cultures, treat any preexisting infection, offer postcoital contraception, arrange medical follow-up, and provide counseling.

In addition, the legal responsibilities are recording events accurately, documenting injuries, collecting forensic specimens, and reporting the assault as required by law. (5)

Rape has three components: (1) carnal knowledge, (2) nonconsensual coitus, and (3) force. Carnal knowledge can range from complete coitus to the slightest penile penetration of the female genitalia. In some states, digital or foreign body penetration may be considered carnal knowledge. Nonconsensual coitus is simply that unless the victim is a minor, intoxicated, drugged, asleep, or mentally incompetent. Force can be either actual or threatened, threats with a real or alleged weapon, or fear of great harm.

The most important fact about the definition of rape is that it is a legal and not a medical definition. The examining physician's opinion as "whether the rape actually occurred" is often solicited but should never be rendered. An emergency medicine physician should become familiar with the laws in his state regarding sexual assault and the age of consent.

First, and foremost, is the identification and treatment of life-threatening injuries. The examining physician should never let the medical examiner perform a rape exam on his patient. Second, after informed consent perform the sexual assault examination to identify forensic evidence and other lesser injuries. The third component is the collection of samples while the examination is in progress. Fourth, is the treatment of minor injuries and prophylaxis against sexually transmitted diseases and pregnancy. Next is the introduction of the services offered by the rape advocate and social services. Finally, the examining physician must, through a chain of evidence, submit the samples collected during the forensic exam to the proper law enforcement authority.

Other than the victim and the examining physician, there several other professionals involved in examination and treatment of a sexual assault victim. When a sexual assault victim presents or the emergency department is notified by law enforcement, the local rape advocacy agency should be contacted and the history and the rape exam deferred until the advocate arrives. While this may jeopardize evidence, the advocate can provide her client with the crucial initial support to relive the ordeal of her assault and to endure the examination. If the law enforcement agency is cognizant and the victim fortunate, the advocate may have acquired the victim prior to presenting the emergency department.

Should the victim present directly the emergency department without contact with law enforcement, the ED staff should make an attempt to establish jurisdiction and contact the appropriate law enforcement agency. More specifically, determine approximately where the assault occurred and contact the department appropriate to that area. After contact has been made, law enforcement needs to be informed a patient has presented alleging sexual assault, has consented (at least verbally to this point) to a sexual assault examination, and she wishes to make a statement. If there is no investigating agency interested or willing to accept the specimens collected, then there is no point in performing the exam.

The rape advocate is generally present with the victim during the exam. She or he acts as an detached party or even a calm voice to help talk the victim through or distract the victim during the exam. The advocate is, therefore, too occupied to assist in the collection of evidence and for this reason the physician should be accompanied by a chaperon (female when possible). Some centers utilize a team of specially educated nurses to perform the bulk of the external exam leaving the perineal exam for the physician. Either system works fine but the names of those examining the patient and handling the evidence must be documented and protocol followed consistently.

The last player is the social worker. The social worker common works in concert with the rape advocate. It may be necessary to find the victim safe haven if the assailant was known to her. Between the advocate and the social worker, appropriate follow-up can be arranged for the psychosocial ramifications of her assault.

Most centers have sealed, standardized rape kits but it may necessary to construct or augment an adequate kit.

The typical standardized rape kit will contain:
* standardized history/physical form (each page with at least 2 carbons)
*1 large paper drop cloth
* 2-3 medium paper drop cloth
* 2 large (grocery size) paper bags
* 2 combs
* 10 small paper envelopes
* 4-6 large paper envelopes
* fingernail clipper
* 6 cotton swabs/sample tubes

* 3 slide boxes with slides
* Styrofoam or bubble pack for blood samples
* 2 2x2 inch gauze pads
* labels

In addition, it will be necessary to bring into the exam room the following:
* 3 agar blood tubes (red or tiger tops)
* 1 citrate tube (purple top)
* N. gonococcus culture kit
* Chlamydia-zyme (or culture medium for pediatric patients)
* Wood's lamp
* Microscope
* phlebotomy equipment


The most important point regarding the sample containers of these kits is that they are either paper or glass. Once sealed, a porous container allows the specimen to "breathe". If moisture is trapped in with a specimen (for example in a plastic bag), it will most likely mildew and the sample will be destroyed. Therefore, wet samples (bloody clothing, semen, or cotton swabbings) must dry completely before they are sealed in a container.

Once the seal of the rape kit is broken the cumbersome task of chain of evidence begins. This is where early communication with law enforcement pays off. The contents of the rape kit and any specimens collected are the responsibility of the examiner until signed over to the police. This translates into the kit in the examiner's physical custody or at least of constant line of sight until relinquished. Any breach in this premise potentially invalidates the evidence.

After presentation to the emergency department, the patient should be asked not to urinate or defecate so as to not taint or destroy any evidence. Every attempt should be made to place these patients into an exam room. Signed consent should be obtained for the exam itself and to release copies of the exam, specimens, x-rays, and clothing to the police. Inform the patient her clothing will not be returned to her after the exam. It is helpful to have a clothing closet or some clothes from the rape advocate so the victim has something to wear at discharge.

A thorough history of a sexual assault should include the following:

Who. Was the assailant known to the victim? Was it a single attacker? A brief physical description.

What happened. Was the victim physically assaulted and if so, with what?

When. When approximately did the assault take place? This will help determine the probability of detecting sperm or acid phosphatase.

Where. Where did penetration occur--vaginally, orally, or rectally?

Last menstrual period. This will help determine pregnancy risk.

Birth control method. This will also determine pregnancy risk and did the assailant wear a condom.

Last consensual intercourse. If the patient had intercourse within 3 days, it may confuse the analysis for sperm and acid phosphatase.

Douche, shower, change of clothes. Any of these activities will jeopardize evidence collection.

Allergies and medical history.

Before the patient disrobes or is examined, take a look at her general appearance. If her clothing is torn, soiled, bloody, get a photograph. A picture is worth a thousand words.

Have the patient step onto the large drop cloth and disrobe. Collect and bag her underpants separately, then bag the remainder of her clothing. Gown the patient for her modesty. Carefully fold the drop cloth and place it in a large paper envelope.

Expose the patient one quadrant at a time and make note of abrasions, lacerations, ecchymoses, or bony deformity. These injuries should be photographed later. Remove any foreign material and place it in a small paper envelope.

Repeat the same external exam with the Wood's lamp. Seminal secretions will illuminate (so will dried urine, blood, and some soil). This can also direct your collection of foreign material later.

Have the patient hold a medium drop cloth in front of her and lower her head over it. Comb her entire head of hair collecting any loose hairs or foreign matter on the drop cloth.


Next pluck at least 10 hairs from her head. You need to collect at least 10 to increase the chance of getting 1 hair with a complete follicle (a complete follicle is needed for hair comparison analysis).

If the assailant ejaculated into the victim's mouth, obtain a swabbing of the oral cavity and prepare a slide. Examine the slide for presence of spermatozoa and note your findings. Then obtain a saline wash of her oral cavity.

Place one of the 2x2 gauze pads in the victim's mouth and allow it to dampen slightly. After drying, place it in a small paper envelope. The other gauze pad is the control for the secretor analysis; place it in an envelope and label it "control".

Using the fingernail clipper, clean any foreign matter from under the fingernails. If the victim's nails are long, torn, or damaged, clip off the excess nail. Place the scrapings/clippings into an paper envelope.

Have the patient lay in the lithotomy position. Repeat your examination of the external perineum (both in plain light and with a Wood's lamp). Photograph any demonstrable injuries. If any suspected ejaculant is detected in pubic hair, clip that material out and place in an envelope and label it with a description.

Place a medium drop cloth under the patient's buttocks and comb the pubic hair for foreign matter. Carefully remove the drop cloth, fold it and place it in a paper envelope.

Next pluck at least 10 hairs from her mons. Again you need to collect at least 10 to increase the chance of getting 1 hair with a complete follicle. Place these in a paper envelope.

Perform a speculum examination of the vagina. Make note of injuries to the labia, introitus, and vaginal walls. Obtain a swabbing of the vaginal cavity and prepare an wet mount slide. Examine this slide immediately for the presence of spermatozoa and make note of their motility.

Obtain samples for chlamydia determination (either by immunoassay or culture) and culture for N. gonococcus. A viral culture for herpes could also be done at this time. These cultures should be sent to your facility's laboratory for analysis.

Perform a saline wash and obtain an aspirate of the vaginal vault if spermatozoa were seen on microscopy.

A dilute solution of sterile water and methylene blue (or toluidine blue) can be used to show the extent of vaginal abrasions. If possible, a photograph of these could be helpful later.

If the anus was penetrated, obtain a swab for spermatozoa and possibly a culture for herpes. Anoscopy can also be performed to establish anal injury.

Obtain four tubes of blood via phlebotomy (one purple and three red/tiger-tops).

Send two red-tops to your lab for HIV ELISA and syphilis serologies respectively. The other purple and red-top go in the rape kit for toxicology and ABO/Rh determinations.
Obtain either urine or serum for a beta-hCG determination.

Depending on the beta-hCG result, the victim should receive antibiotic and/or pregnancy prophylaxis:

Ceftriaxone 250mg I.M. * or Cefixime 400mg P.O. * or Ofloxacin 400mg P.O.
PLUS

Doxycycline 100mg P.O. bid for 7 days or Azithromycin 1 gram P.O. *
PLUS
Metronidazole 2 grams P.O.
* Suitable in pregnancy

Two oral contraceptive tablets (50ug ethinyl estradiol) or Three oral contraceptive tablets (35ug ethinyl estradiol). One dose in the ED and a second dose in 12 hours

Optional: Sedative and/or anti-emetic