Examination The responsibilities of physicians providing immediate treatment for sexual assault survivors are listed in Table 11.8. Many health care facilities have trained sexual assault nurse evaluators (SANE). Because of the legal ramifications, consent must be obtained from the patient before obtaining the history, performing the physical examination, and collecting forensic evidence. Documentation of the handling of specimens is especially important, and the chain of evidence for collected material must be carefully maintained. Everyone who handles the evidence must sign for it and hand it directly to the next person in the chain. The chain of evidence extends from the examiner, to the police detective, to the crime laboratory, and finally to the courtroom.
Table 11.8 Prophylactic Medications Following Sexual Assault
IM, intramuscularly; PO, by mouth; bid, twice a day; qid, four times a day; Td, tetanus and diphtheria; IUD, intrauterine device.
The patient should be interviewed in a quiet and supportive environment by an examiner who is objective and nonjudgmental. Support personnel and patient advocates, such as family, friends, or, if available, a counselor from a rape crisis service, should be encouraged to accompany the patient. It is important not to leave the survivor alone and to give her as much control as possible over the examination. To provide useful forensic information, the examination should be performed as soon as possible after the incident occurred. Providers in all 50 states are required to report all cases of suspected or known childhood sexual abuse to appropriate authorities.
The history should include the following information: 1.
A general medical history and a gynecologic history must be obtained, including last menstrual period; prior pregnancies; past gynecologic infections; tetanus immune status; history of liver disease, thrombosis, or hypertension (possible contraindications to emergency contraception with estrogens); contraceptive use; prior sexual assault; and last consensual intercourse before the assault.
2.
It is important to ascertain whether the survivor bathed, douched, used a tampon, urinated, defecated, used an enema, brushed her teeth or used mouthwash, or changed her clothes after the assault. These activities can impair the collection of forensic evidence.
3.
A detailed description of the sexual assault should be obtained, including the place, time, and date of the assault; number and appearance of assailants; use of drugs or alcohol in relation to the assault; loss of consciousness; use of weapons, threats, and restraints; and any physical injuries that may have occurred.
4.
A detailed description of the type of sexual contact must be obtained, including whether vaginal, oral, or anal contact or penetration occurred; insertion of a foreign object with a description of the object; whether the assailant used a condom; and whether there were other possible sites of ejaculation or oral contact, such as the hands, clothes, breasts, or hair of the survivor. Saliva, respiratory spray, or semen recovered from these sites could yield DNA from the assailant.
5.
The emotional state of the survivor should be observed and recorded.
The physical examination serves to detect, evaluate, and treat all injuries and to collect forensic evidence (152). It is important, when examining survivors, to pay close attention to detail. Examiners should wear powderless gloves at all times in order to prevent contamination of the evidence with their own DNA.