The General Approach and Management of the Patient Who Discloses a Sexual Assault

Abstract

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.

Introduction

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.

Approach To Survivors of Sexual Assault

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 outlines these antidotes and recommends concrete application of these TIC tools for most sensitive approach and practice. ⁵

Table 1.

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

Table 2.

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)

^*Adapted from the International Association of Forensic Nursing

Triage, Medical Evaluation, and Treatment

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

Consent

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 Forensic History

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.

Forensic Sexual Assault/Evidentiary Examination

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 2.)

Figure 1.

1 Erythema (redness)

Tenderness–noted laceration vestibule and labia minora between 10 and 11 o’clock active bleeding noted

2 Erythema (redness)

Swelling

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

Figure 2.

1 Laceration/Tear

Tenderness from the fossa navicularis to the posterior fourchette between 7 and 6 o‘clock

2 Laceration/Tear

Tenderness - noted on the left labia minora at 5 o’clock

3 Laceration/Tear

Tenderness - noted on left labia minora between 4 and 5 o’clock

4 Laceration/tear

Tenderness laceration between 4 and 5 o’clock left labia majora

*7.3 hours post assault

Chain of Custody

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.

Drug Facilitated Sexual Assault

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

Examination

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.

Prophylactic Medications

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.

Table 3.

Recommended STD and Pregnancy Prophylaxis and Follow-up

Offending Agent	Recommended Prophylactic Treatment	Recommended Follow-up
N. gonorrhoeae	Ceftriaxone 250 mg IM single dose	None recommended if prophylaxis given
C. trachomatis	Azithromycin 1 gram single oral dose or Doxycycline 100mg twice daily orally for 7 days	If no prophylaxis given follow-up in 1–2 weeks for repeat cultures
T. vaginalis	Flagyl 2 gm orally single dose	None recommended if prophylaxis given
Hepatitis B	HepB vaccine without HBIG	Follow-up doses should be given at 1–2 months and 4–6 months after first dose.
T. pallidum (syphilis)	NONE	Follow-up serum/serologic tests at 6 weeks and 3 months
HIV	The preferred PEP regimen for sexual assault is the same as that for other types of non-occupational exposures and occupational exposures: Tenofovir 300 mg PO daily + Emtricitabine 200 mg PO daily Plus Raltegravir 400 mg PO twice daily or Dolutegravir 50 mg PO daily See HIV Prophylaxis Following Non-Occupational Exposure for regimen considerations when the source is known to be HIV-infected, dose adjustments for patients with renal insufficiency, drug-drug interactions, and recommended alternative regimens.	Repeat serologic testing at 6 weeks, 3 months, and 6 months
Pregnancy	Emergency contraception with Plan B or equivalent within 72 hours of vaginal penetration (consider anti-emetic)	Consider pregnancy test for confirmation at 2 weeks
Tetanus	Give dT immunization: If skin abrasions and immunization status is unknown or greater than 10 years If high risk wound and immunization status greater than 5 years Add Tetanus Immune Globulin (Hypertet) 250U IM to dT immunization (in separate arms) if high risk wound and no history of immunization or < 3 doses

Follow-up Services

When providing discharge instructions, include a summary of the exam (e.g., evidence collected, tests conducted, medication prescribed or provided, information provided, and treatment received), medication doses to be taken, follow-up appointments needed or scheduled, and referrals. The discharge form could also include contact information and hours of operation for local advocacy programs.² Patients should be instructed to follow up for re-evaluation at appropriate intervals. In the days following the assault it may be indicated to document developing or healing injuries (for example, bruising) and complete resolution of healing or further evaluate nonspecific findings. At minimum, the patient should be scheduled for follow-up two to four weeks post assault for STI evaluation and Care, HIV testing, and administering doses of Hepatitis B vaccine if indicated.²

Address the patient’s physical safety and emotional well-being. Screen for domestic and dating violence and others forms of abuse. Assist patients in considering things such as:

Where are they going after being discharged? With whom? Will these individuals provide them with adequate support? (Provide information about available community resources for obtaining support and help in making the contact if needed.) Is there a need for emergency shelter or alternative housing options? (Provide options and help obtain if needed.) Are they eligible for protection orders? (Provide information and help obtain if desired.) Is there a need for enhanced security measures? (Discuss options and help obtain if desired.) If they feel unsafe, what will they do to get help? (Discuss options and help them develop a plan.) Planning must take into account the needs and concerns of specific populations. For example, if patients with physical disabilities require shelter, the shelter must be accessible and staff able to meet their needs for personal assistance with activities of daily living. ²

Court Testimony

The SAFE examiner is performing a service to the patient by collecting evidence that could be used in a criminal proceeding during a health care examination. This naturally places the examiner as a witness in any criminal proceedings as a result of this exam, and is considered part of the role. Prepare and maintain a Curriculum Vitae. Be prepared to prove and explain qualifications and discuss educational background, clinical experience, and prior experience as a witness. Review medical forensic report, photographs, and the results of evidence analysis as part of your preparation. Meet with attorney(s) in advance and be prepared to discuss the case as well as any subsequent contact with the patient. During testimony, educate the judge/jury on terminology, SAFE procedure, policy, specifics of this exam.

Sexual Assault Response Team (SART)

The members of the SART may include but are not limited to: Sexual Assault Nurse Examiner/ Physician, Patient Advocate, Crime Lab, Law Enforcement, Prosecutors and Health Department. The goal of the team is to develop a recommended set of evidence-based practice guidelines for individuals working with survivors of sexual assault to ensure a coordinated consistent effort among these agencies. The SART should lead the community in the appropriate response by setting policy, identifying needs, and evaluating efficacy of their practice. The commitment of each SART member should include education of community during outreach, strict moral and ethical standards, and ultimately facilitate the healing process for survivors.

Conclusion

Providers that deliver care to survivors of sexual assault have the duty to facilitate comprehensive medical care, a sensitive TIC response, competent forensic documentation and evidence collection, supportive and safe discharge planning, and fact and/ or expert testimony. Providers are encouraged to seek out the recommended 40 hour Sexual Assault Nurse Examiner (SANE) training as outlined by the International Association of Forensic Nurses and become board certified. Competent forensic care ultimately improves the reporting of sexual violence and successful prosecution of perpetrators and can aid in the physical and emotional healing of a patient that has survived a sexual assault.

Biography

Srikala Subramanian, MD, is an Assistant Professor at University of Missouri-Kansas City School of Medicine and KCSANE Medical Director at Truman Medical Center. Jennifer S. Green, RN, BSN, BA, SANE-A, is the Kansas City Sexual Assault Nurse Examiner (KC SANE) Program Manager. Both are at Truman Medical Center in Kansas City, Missouri.

Contact: Srikala.Subramanian@tmcmed.org