Exact details of the examination will vary depending upon state and local evidence collection requirements. Some states have provisions for special Sexual Assault Nurse Examiners (SANEs) who are specially trained to perform the complete sexual assault examination and testify if the case is prosecuted. Other regions have a sexual assault team (SART) with representatives from healthcare, forensics, rape crisis centers, law enforcement, and the prosecutor's office. SANE and SART programs increase compliance with recommended medical care, quality of evidence collection, and the likelihood that charges will be filed and successfully prosecuted.3
The order of the examination may vary depending upon the patient's needs. The Emergency Department is often the first official system to which the victim reports an assault. Patients may be reluctant to share their story with personnel in the criminal justice system if they are met with judgmental attitudes or insensitive treatment by emergency medical staff.12
Collect a urine sample early if there is any possibility of the use of a “date rape” or “club drug.” The decision to process the urine can be determined later. The window to detect drugs such as gamma-hydroxybutyric acid (GHB) or Rohypnol (flunitrazepam) can be as little as 8 hours after ingestion. Most toxicology screens will detect prescription drugs and recreational drugs that the patient may have taken. For this reason, some patients may decide not to have their urine tested.
Proceed with the history and physical examination once the patient is in a private room, has consented to the examination, and an advocate is made available. Obtain a complete history to guide the medical examination and help with possible legal matters (Figure 139-2). Avoid judgmental questions that may feed into the victim's feeling of self-blame. Aspects of the history should include the time and place of the assault, the race, gender, and number of assailants. Obtain and document a brief description of the assault including whether there was oral penetration, vaginal penetration, rectal penetration, and/or ejaculation. Elicit any use of force, restraints, foreign bodies, or lubricants. Ask the patient what they have done since the assault. Simple things such as changing clothes, douching, bathing, urinating, defecating, or using a tampon may change the ability to collect forensic evidence.
Sample history form. Courtesy of Illinois State Police.
The past medical history should emphasize the gynecological history and include last menstrual period, type of birth control used if any, last consensual intercourse, previous sexually transmitted diseases, previous pregnancies, and previous gynecological surgeries. The time of the last voluntary intercourse is important, as mobile sperm may be found up to 72 hours in the cervix. Determine the tetanus immune status and provide immunoglobulin and boosters if needed. Determine if date rape drugs might have been given, especially if there seems to be a lapse of time between the assault and presentation to the ED.
The physical examination serves to detect injuries and document them for future legal prosecution. A complete physical examination must be performed, even if the patient does not want to pursue legal matters. Although up to 70% of rape victims reported no physical injuries, 4% to 5% sustained serious physical injury, and 24% sustained minor physical injuries.1,13 It is important to help patients guide the examination and allow them to stop at points if they are not ready to proceed. Many patients will need encouragement through the examination.
Note the patient's general appearance, affect, and emotional status. Instruct the patient to disrobe over a clean paper sheet if they are wearing the same clothes they wore prior to the assault. Place all clothes in paper bags, with the underwear in a separate paper bag. Fold the paper sheet, containing any debris, and place it in a collection envelope. Examine the entire body for abrasions, lacerations, bites, scratches, foreign bodies, and areas of ecchymoses. Closely examine every laceration to ensure it is not a stab wound. It is helpful to use a body diagram to document injuries (Figure 139-3).
Sample general physical examination form with body diagrams. Courtesy of Illinois State Police.
Genital trauma after consensual sex is uncommon. However, genital injuries commonly occur after sexual assault at the posterior fourchette, labia minora, fossa navicularis (anterior to the fourchette), and hymen.11 Commonly injured nongenital areas include the mouth, throat, wrist, breasts, and thighs.12 Oral cavity injuries are common and include a torn frenulum and broken teeth. Bite marks on the genitalia and breast are common.14 Use a Wood's lamp to examine the skin for fluorescent stains that may represent semen. Use an instant camera or a hospital photographer to document any bites, lacerations, scratches, abrasions, or any other injuries. Photographs are much more informative than body diagrams.
Collection of forensic evidence usually precedes the gynecological examination unless the patient is bleeding, has severe lower abdominal pain, or has pelvic pain. Most states have set evidence collection kits and the elements required will vary. Evidence is usually helpful up to 5 days after an assault. It is recommended to collect evidence up to a week after an assault as patients may not recall the dates exactly. Most sexual assault kits require fingernail scraping, head hair combing, saliva specimens, and blood type screening. Swab any stain on the patient's body that fluoresces under the Wood's light. Swab all orifices (oral, vaginal, and anal), even if not penetrated, as recollection of events may change and a negative examination in a nonpenetrated area helps to validate the patient's story. Use only sterile water or sterile normal saline to moisten a swab. Obtain samples of the patient's saliva by having them bite on a piece of filter paper in the kit. Obtain a sample of the patient's blood. Place five or six drops of blood on a piece of filter paper. Use a wooden stick to scrape under all the patient's fingernails over a piece of white paper to collect the scrapings. Allow all specimens to air-dry before placing them in envelopes.
Collect hair samples from the victim. Pluck two or three hairs from the scalp hair and place it in a labeled envelope. Comb the patient's pubic hair over a white piece of paper. Place the comb, paper, and any hair or debris in a labeled envelope. Pluck two or three hairs from the pubic region and place them in a labeled envelope. The process of plucking hairs is painful and somewhat insensitive to the patient. Consider asking the patient to pluck the hairs for the evidence collection. This allows them to actively participate in the process. These hair samples can also be obtained later if the case is prosecuted, as the patient's hair samples will not change. Cutting off pieces of hair is of no value as the roots of the hairs are required for the forensic evidence process.
Inspect the mouth and perioral structures for any signs of trauma. Carefully inspect the frenulum of the lower lip and tongue for bruising or tears. Examine the tonsils, the tonsillar pillars, and the oropharynx for bruising or lacerations. Swab the oral cavity thoroughly and allow the swabs to air-dry. These will later be tested for sperm acid phosphate and the victim's blood group antigens. Obtain additional swabs for gonorrhea and chlamydia testing in the hospital laboratory. Prepare a wet mount to look for motile spermatozoa.
Thoroughly examine the anorectal area for signs of trauma. This includes abrasions, ecchymoses, and lacerations. Swab the rectum and anal canal. Send one swab to the hospital laboratory for gonorrhea and chlamydia testing. Place the remainder of the air-dried slides in envelopes for later sperm and acid phosphatase testing.
The gynecological examination is usually the most traumatic aspect of the examination for the patient. It may remind them of the assault. Explain all procedures in simple terms prior to beginning. Allow the patient to help guide the examination. Do all forensic evidence collection, including combing for pubic hairs and vaginal swabs, at the same time as the gynecological examination. Close attention to the external genitalia is important, as many patients are asymptomatic (Figure 139-4). Eight percent of patients have vulvar trauma.15 Only use sterile water to lubricate the speculum. Lubricants interfere with forensic evidence collection. Examination of the hymen is important, as it is one of the most common areas of injury. A person's previous sexual history helps predict the location of lacerations of the vaginal wall. Lacerations are seen near the introitus in less sexually experienced patients and higher in more sexually experienced patients.
Sample physical examination form with diagrams for the genital examination. Courtesy of Illinois State Police.
Collect baseline gonorrhea and chlamydia swabs at the time of the pelvic examination from pooled vaginal secretions and the endocervical canal. Obtain additional swabs to test for sperm acid phosphatase and blood group antigens. Colposcopy is used to detect and document more subtle injuries of the cervix and vagina. One study showed that colposcopy increased detection of genital trauma from 6% to 53% of victims.16
Toluidine blue can be used to identify small lacerations and abrasions that result from traumatic intercourse. It can increase the chances for detection of lacerations in sexual assault victims. Apply the dye with a cotton-tipped applicator to the external genitalia and wipe off the excess. Document and photograph any areas of uptake to toluidine blue. Toluidine blue should be used prior to the speculum examination, as the speculum can result in small lacerations that uptake the dye. Unfortunately, the dye is spermicidal and can interfere with wet mount examinations.