Sexual Assault

The victim is unwilling to notify authorities or seek medical attention for fear of personal humiliation.
The victim is unwilling to notify authorities because she fears retribution.
The victim, particularly in cases of incest or close personal relationships, does not wish to disturb the family or friendship unit, dysfunctional though it may be.
The victim is not aware that the crime occurred. (eg, when illegal drugs or alcohol are involved)

Sexual assault is usually not a crime of sexual gratification, but rather expresses power, anger, hostility or aggression.

Although the stereotypical perpetrator of sexual assault is a stranger, in real life, the rapist is often known to the victim. This situation is known as "acquaintance rape" or, when applicable, "date rape."

Sexual assault is an act of violence with medical, mental and legal issues which should to be addressed. Described below is a standard medical approach to sexual assault when resources are available and clinical circumstances allow.

Let’s consider a basic strategy for management.

First, evaluate the patient for serious injuries (fractures, hemorrhage, etc.) which might require immediate treatment.
Obtain a brief history, explaining to the patient what will occur next. Obtain patient's consent.
Gather all necessary materials and notify legal and administrative authorities.
Examine the patient, obtaining various specimens.
Offer treatment for STDs, pregnancy.
Arrange for follow-up care.

Now for some specifics:

Serious injuries come first
If the patient has serious injuries, take care of the injuries before worrying about collecting legal evidence. Patient care takes priority.

Notify Legal and Administrative Authorities
Early in this process, legal and administrative authorities need to be notified that a sexual assault has been reported and medical care is being provided. Depending on your location, this might include local, county, state or federal law enforcement agencies.

Notify Social Services
In some settings, a sexual assault counseling service is functioning and can be contacted. In other settings, social workers or other support personnel are used for this purpose. Sometimes, a chaplain serves the role of a social service provider and should be notified of this occurrence.

Chaperone
Customs vary regarding the use of a chaperone in general OB-GYN practice, but they don't vary at all in the context of a sexual assault victim. It is important to have a medical chaperone (preferably someone from the nursing community) who can be a witness, both to the history-taking and the physical exam. This person can also provide valuable comforting and support to the victim.

Gather your supplies before starting your exam
Before you actually examine the patient and begin collecting your exam specimens, it is best to gather all the materials you will need first. This saves you time and spares the patient the unpleasantness of a prolonged examination. It also helps you avoid forgetting something. If you think you have completed your exam, but you still have some supplies left, you probably forgot about something.

In many areas, "Sexual Assault Investigation Kits" are prepared in advance, containing everything needed for this examination. If a pre-packaged kit is not available, you may wish to consider making your own prior to the need for it arising. All specimens should be properly labeled and maintained by precise chain of custody.

Labels
Every specimen taken from the patient must be properly labeled. The label should include:

Patient's name
SSN or other unique identifier
Date
Time
Identity of specimen (e.g., "fingernail scrapings)
Location (e.g., "right hand")
Examiner's initials

It is helpful to make up your labels before you examine the patient. In addition to labels for all of the specimens, you will need to label lab requisitions, your medical report, and the consent forms. You will need at least 25 labels, not counting any labels used on laboratory requisitions.

Consent
Consent should be obtained from the patient to:

Examine her and provide medical treatment.
Collect evidence.
Taking photographs (if indicated).
Release medical reports and evidence to legal authority.

History
There may be a balance between obtaining enough information to effectively treat the patient and asking questions that make the patient uncomfortable. While some assault victims are anxious to discuss what just happened to them, many more are silent and withdrawn, exhausted from their experience.

Ask the patient what happened. Ideally, she will need to be as specific as possible about exactly what was done to her, when, where, by whom, etc.

Write down her description of what happened, but remember that you are not in a position to judge whether a rape or sexual assault occurred...you are simply repeating what the patient told you. For example, you might say, "Patient states she was raped today at 4:00 pm by an unknown person in Municipal Park."

You should not write, "The patient was raped at 4:00 pm," because that implies a legal conclusion on your part. You should also not say, "The patient was allegedly raped at 4:00 pm," because this use of the word "allegedly" has been interpreted by some people to imply that you didn't believe that a rape occurred. It is better to simply condense and repeat what the patient told you.

Gynecologic History
Particularly important are:

LMP
Use of contraceptives, such as BCPs
Any significant past gynecologic history
Sexual history: You need not obtain a detailed sexual history, but two issues are important to explore with the patient: first, whether she has ever had sexual intercourse prior to the sexual assault, and second, the last time sexual relations occurred within 72 hours prior to the assault.

Clothing
If any clothing contains moist or dry stains, remove the clothing, let it dry completely, and place it in a paper bag (not plastic).

Use one paper bag for each piece of clothing.
Seal each bag and label it.
The clothing should be given to the law enforcement authorities and signed out using a chain of custody form.
Give the patient a property receipt card for her clothing.

Physical Exam
Start at the patient's head and work downward, explaining to her what you are doing as you examine her and collect specimens. If you encounter any physical evidence of trauma, you should draw a picture of your findings and, if possible, photograph the evidence.

Photographs
Take the photographs yourself, without a photographer being present, particularly if the trauma involves areas around the breasts or perineum.

Head Combings
Lightly comb the patient's hair over a plain white sheet of paper. Fold the paper over the comb and any loose hairs and place everything in an envelope. Seal and label it.

Do not pluck hairs from the head to serve as controls. While obtaining plucked hairs is recommended by some law-enforcement agencies, this is a painful and humiliating experience for the patient and almost never makes any difference in the final legal outcome of the case.

If the law-enforcement jurisdiction in which you are located later requires plucked hairs, they can ask for them at that time.

Mouth
Using two dry cotton-tipped applicators, gently obtain a specimen from each side of the gums, both right and left, top and bottom. Smear the specimen on a glass slide and let it air-dry. Place the dried glass slide in a cardboard slide holder, label it and seal it. Let the cotton swabs air-dry and then place in an envelope, label it and seal it.

Use another dry cotton swab to obtain a specimen for smearing on a chocolate agar plate or specialized collection medium to test for gonorrhea. Label the plate, discard the swab and send the plate to the laboratory.

Ask the patient to place one piece of filter paper in her mouth to become saturated with saliva. She should not chew the filter paper. When saturated, ask her remove it from her mouth with her own fingers and place it in an envelope. Do not touch the filter paper yourself. Let the filter paper air-dry. Then seal it.

Carefully inspect the oral cavity, using a tongue blade and flashlight, noting any evidence of trauma.

After examining the mouth, offer the patient a toothbrush and toothpaste and mouthwash to rinse her mouth. Particularly if oral contact was involved in the assault, she will feel much better after cleansing her mouth. This will also give her a psychological break in the exam.

Neck, Back, Breasts, Abdomen and Arms
Inspect and palpate for any evidence of trauma, lacerations, bruises, abrasions, tenderness, etc. Record any significant findings.

Hands
Collect fingernail scrapings using the wooden toothpicks, one for each hand. The patient may do this herself with you observing.

Place the scrapings and the toothpicks in two envelopes, one for the right hand and one for the left hand. Label and seal them.

Pubic Hair Combings
Lightly comb the pubic hair over a plain white piece of paper. Fold the comb and any loose hairs into the paper, place in an envelope, label and seal it. There may not be any loose hairs.

Do not pluck hairs from the pubic area to serve as controls. If the law-enforcement jurisdiction in which you are located later requires plucked hairs, they can ask for them at that time.

Inspect the Vulva
Using good light, carefully inspect the vulva for signs of trauma, lacerations, bruises, abrasions, etc. Note the status of the hymen.

Application of toluidine blue dye (rinsed with vinegar) can highlight recent trauma. The dye is retained by metabolically active cells.

Visualize the Cervix
After moistening the vaginal speculum with warm water, insert it into the vagina and inspect the vagina and cervix for signs of trauma.

Vaginal Swab
Using two dry cotton-tipped applicators, swab the vaginal walls and posterior fornix (area beneath the cervix). Smear this specimen on a glass slide, allow it to air-dry and place it in a cardboard slide holder. Label and seal the slide holder. Let the cotton swabs air-dry and then place them in an envelope. Label and seal the envelope.

Do not try to examine the vaginal or cervical specimens for motile sperm unless you are experienced in this technique. Forensic pathologists will examine the dried slides and their skills are considerable. You may jeopardize later legal proceedings if you inartfully look for motile sperm and reach conclusions which are different than those of the forensic pathologist. From this perspective, it is better to leave the microscopic examinations to the experts unless you have experience and training in this area.

Chlamydia Culture
Use your chlamydia test kit to obtain a cervical specimen.

Gonorrhea Culture
Use a dry cotton swab and chocolate agar plate or other suitable technique to obtain a specimen from the endocervical canal. Label the plate and send it to your laboratory.

Rectal Inspection and Examination
In the case of rectal assault, inspect carefully for tears or breaks in the skin of the rectum.

Toluidine Blue dye can be helpful. An anoscope can be used to inspect the lower rectum.

Use two cotton-tipped applicators, moistened with distilled water, to obtain a specimen from just inside the rectal sphincter. Smear this specimen on a glass slide, allow it to air-dry and place it in a cardboard slide holder. Label and seal the slide holder. Let the cotton swabs air-dry and then place them in an envelope. Label and seal the envelope.

Use another moistened cotton-tipped applicator and a chocolate agar plate to test your patient for gonorrhea. Send this specimen to your lab.

Bimanual Exam
After collecting all specimens, perform a bimanual exam. Using the lubricating jelly, palpate each of the pelvic structures, noting any enlargement or tenderness.

Betadine Douche
Once the pelvic examination is completed, a cleansing douche of Betadine mixed in water may be appreciated by the patient. 50 to 100 cc of solution can be used to rinse the vagina, using a 30 or 50 cc syringe. Collect the rinse in the emesis basin and discard.

Let the patient shower and change clothes
This is important for her psychological health. Usually, there are no major physical injuries after a sexual assault, but the psychological injuries can be great. A part of your treatment will be to reassure her that she's "OK" and to assist her in the cleansing process (physical and mental). Once the specimens are collected, she should be given the opportunity to shower and change clothes, in a sense "washing away" some of the unpleasantness of her recent experience. Some women will decline, preferring to shower later, but many will appreciate the offer and will feel better afterward.

Some Blood and Urine Tests are appropriate

VDRL or RPR - repeat in 1 month
Hepatitis B - repeat in 1 month
HIV - repeat in 1 month and 6 months
Pregnancy test - repeat weekly until next menstrual flow
1 extra red-top tube for the Investigator
Place 4-5 drops of the patient's blood (taken from the needle or drawn from one of the red-top tubes) on a piece of filter paper and let it air-dry. Place the filter paper in an envelope, label it and seal it.

Offer Antibiotics
The risk of acquiring gonorrhea from a sexual assault is approximately 6 to 12% according to the CDC, and the risk of acquiring chlamydia probably a little higher. The risk of acquiring syphilis is estimated at about 3%. The risk of developing AIDS from a sexual assault cannot be precisely estimated as it depends on too many factors but is considered to be quite low.

Standard prophylaxis:

Ceftriaxone 125 mg IM, plus
Azithromycin 1 g PO once (or Doxycycline 100 mg PO BID x 7 days), plus
Metronidazole 2 g PO once

Postexposure hepatitis B vaccination (without HBIG) should adequately protect against HBV. Hepatitis B vaccine should be administered to victims of sexual assault at the time of the initial examination. Follow-up doses of vaccine should be administered 1-2 and 4-6 months after the first dose. For those known to have completed a full HBV vaccination program, additional Hepatitis B vaccine need not be given.

Offer Emergency Contraception
The exact risk of pregnancy following a sexual assault is estimated at about 2-4%, but depends to a large extent on where the woman was in her menstrual cycle and, of course, whether she was protected by some contraceptive method.

Taking 2 medium-strength BCPs (Ovral) right away and again 12 hours later has been used successfully by many physicians to prevent pregnancy. Alternatively, 4 LoOvral can be taken immediately and again 12 hours later.

Such a dosage is well-tolerated by most women, but half will experience nausea which might require anti-nausea medication. After using this protocol, the woman's normal menstrual cycle should not be disturbed and she will not have any withdrawal bleeding after she completes this 4-pill regimen.

This method reduces the risk of pregnancy by 75%. It's exact mechanism of action is not known but may involve postponing ovulation and may involve prevention of implantation. Should a pregnancy occur despite the use of emergency contraception there is no evidence of any harm to the fetus.

You need to advise your patient of these issues, and let her decide whether she wishes to take emergency contraception. Whatever her decision, you should document in the medical record your discussion and her decision.

Follow-up exam
About 2 weeks after the assault, the patient should be re-examined for any lingering injury and also to provide reassurance that at least physically, everything is totally back to normal. At this time, she will have had a menstrual flow (typically), and she can have her follow-up labs (HIV, VDRL, Hep B) done at the same time. This will also allow you an opportunity to see how she is dealing with the psychological issues related to the assault.

Ideally, serologic tests for syphilis and HIV infection should be repeated 6, 12, and 24 weeks after the assault if initial test results were negative

For psychological reasons, some women may need to be seen earlier than 2 weeks to reassess their adaptation to this trauma.

Release from Medical Department
After the patient has been examined and treated and all specimens collected, she may be released. She should not be released alone, but rather in the company of someone she knows and trusts. It is important that she feels she is going to a safe place.

Write your Report
Make this factual, but it need not be lengthy.

Do not draw legal conclusions about whether a sexual assault occurred or did not occur.
That is for the courts to decide.

Give Evidence to Investigator

Using a proper Chain-of-custody form, sign over the evidence to the law enforcement representative, consisting of:

Clothing
Copy of Consent to Release Information
Copy of your Medical Report
Glass slide of oral specimen
Glass slide of vaginal specimen
Glass slide of rectal specimen
Swabs of oral specimen
Swabs of vaginal specimen
Swabs of rectal specimen
Filter paper with saliva
Filter paper with 4-5 drops of patient blood
Combings of head hair
Combings of pubic hair
1 red-top tube of patient's blood

Give specimens to your lab
The laboratory specimens which you obtained for patient care reasons should go to your laboratory, but may be handled in the routine fashion and not following a Chain-of-Custody procedure. They will consist of:

Gonorrhea plate from the mouth
Gonorrhea plate from the cervix
Gonorrhea plate from the rectum
Chlamydia test kit from the cervix
Pregnancy test specimen
Red-top tube for VDRL, Hep B and HIV

Give prescriptions and Instructions to patient
The patient should have everything she needs to get her follow-up medications. In addition, she should have written instructions on where to be and for what purpose:

Antibiotics
BCPs (antiemetics optional but recommended)
Dates for weekly pregnancy tests
Date for 2-week follow-up exam and labs (VDRL, Hep B and HIV)
Date for 6, 12 and 24-week follow-up lab (VDRL, HIV)
Name and phone number or location of law enforcement Investigator
Name of Chaplain (or social service person) and phone number or location.

The special case of children
Children who are victims of sexual assault need special attention and may require some modifications of the general outline.

Small children may not have an appreciation of exactly what happened to them, or may be unable to express themselves. Some experienced examiners will have the child use dolls to demonstrate what happened.

During sexual assault of a prepubertal child, serious internal injuries may occur, including laceration of the vaginal wall and tearing of the uterus from its' supports at the top of the vagina. Rectal injury may occur. Because of this, it may be necessary to obtain other tests (upright abdomen looking for free air in the abdomen), or to examine a child under anesthesia to determine the extent of the injuries. Intra-abdominal injuries promptly diagnosed and treated will usually have an excellent prognosis. The same injuries diagnosed after peritonitis has become well-established are more grave.

Return to the OBGYN Morning Rounds Home Page

This information is provided by The Brookside Associates, a private organization, not affiliated with any governmental agency. The opinions presented here are those of the author and do not necessarily represent the opinions of the Brookside Associates. The patients presented and discussed here are fictitious and are merely representative of clinical conditions. Any resemblence to real patients is purely coincidental and not intentional.

For any clinical condition, many alternative diagnostic and therapeutic efforts may give satisfactory or superior results. The clinical approaches presented here are not intended to reflect and do not reflect the only way to provide good care for these patients.

This information is provided solely for educational purposes. The practice of medicine and surgery is regulated by statute and restricted to licensed professionals and those in training under supervision. Performing medical procedures outside of that setting is a bad idea, is not recommended, and may be illegal.

The presence of any advertising on these pages does not constitute an endorsement of that product or service by the Brookside Associates.