Sexual Assault Forensic Medical Examination

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					Sexual Assault Forensic
 Medical Examination:
 Maximizing Objective Findings

             Jo Stearns, PA-C
       Dekalb Emergency Physicians
          Dekalb Medical Center
            Decatur, Georgia

Investigating Allegations of Staff Sexual Misconduct with Offenders
                          July 15 – 20 2007
    Sexual Assault Medical
     Forensic Examination
This protocol will facilitate:
• Consistency
• Comprehensive approach
• Sensitivity
• Non-judgmental treatment of
  victims of sexual assault
    Dual Purpose of the Exam:
        Patient Centered
•   Evaluate and treat injuries
•   Conduct prompt examinations
•   Provide support and counseling
•   Prophylaxis against STD’s
•   Assess women for pregnancy risk and
    discuss options
•   Provide medical/mental health follow-
    Dual Purpose of the Exam:
        Criminal Justice
•   Obtain a history of the assault
•   Document exam findings
•   Properly collect, handle and analyze
•   Interpret and analyze findings (post-
•   Present findings and provide expert
    opinion related to exam/evidence
   Multidiscplinary Process
Utilizing a multidisciplinary team offers
 expertise from:
  • First Responders
  • Sexual assault forensic examiners
  • Law enforcement representatives
  • Victims advocates
  • Prosecutors
  • Forensic photographers
          Patient-Centered Care
•   Ensures patient privacy   •   Respects patient’s
                                  request for providers of
•   Provides a “safe”             a specific gender
    environment and
    acknowledges safety       •   Integrates exam
    concerns                      procedures

•   Accommodates victims      •   Involves victim services
    request for family or a       and law enforcement
    friend to be with them
    Common Reactions To Sexual
• Emotional Shock
• Denial, Disbelief, Shame, Guilt,
  Helplessness, Anger, Fear, Anxiety
 Patient’s Behaviorial Changes

• Calm
• Withdrawn
• Expressive
• Nightmares
• Change in habits, normal routine
• Rape Trauma Syndrome / PTSD
      Rape Trauma Syndrome
•   Human reaction to an unnatural event
•   Three Phases:
    – Acute Crisis Phase
          – Immediate reaction
    – Outward Adjustment Phase
          – Need for “normal routine”
    – Integration Phase
          – Accepting the event
    – Reactivation
          – Mimics the acute phase
Needed Mental Health Services:
  Rape Crisis Interventions
 – Some communities have rape crisis counselors
   who will meet inmates at the hospital and act as
   advocates during SANE Exams

 Mental Health evaluation

 Group counseling (in some situations
            Partnering with Local
                Crisis Centers
PROS                           CONS
– Specialized training for     – Counselors may not be
  care of sexual assault         trained in dealing with
  victims                        inmates or regulations of
– Victims may be more            correctional
  comfortable with a             environments
  provider outside of the      – May not agree with or
  correctional institution       understand policies that
– Ability to provide a wider     may go against ethical
  range of services              codes and beliefs
    Components of Forensic
     Medical Examination
• Consents
• Sexual Assault History
• Physical exam:
   – body maps
   – standardized colposcopy
• Treatment plan:
   – Prophylactic Treatment for STD
   – Post-coital contraception
   – Medical and MH follow up
Obtain both verbal and written:
• General medical care

• Pregnancy testing / EC

• Prophylaxis for STD

• HIV testing / prophylaxis

• Permission to contact patient
•   Release of medical information
•   Forensic exam AND evidence collection
•   Photographs including colposcope
•   Toxicology screening
•   Release of forensic information and
       Sexual Assault History
•   Obtain the medical forensic history in a
    private and quiet space

•   Coordinate with other responders,
    information that is respectful to the

•   Avoid repetition of questions
      Sexual Assault History

•   Date and time period
•   Number of assailants
•   Name of assailants
•   Location of assault
•   Physical surroundings
       Sexual Assault History
•   Were there weapons involved?
•   Threats of harm / injuries inflicted?
•   Physical blows, choking, biting?
•   Physical restraints?
•   Involuntary ingestion of drugs or
•   Loss of consciousness?
     Sexual Assault History

Description of the sexual assault:
• Penetration of anus, vagina, oral

• Oral contact with genitals

• Other contact with genitals

• Use of foreign objects

• Digital penetration
      Sexual Assault History

•   Ejaculation
•   Use of contraception or lubricants
•   Last menstrual period
•   Last consensual sex
           Physical Exam
•   Head to toe
•   General body survey
•   Cardiovascular
•   Abdominal
•   Pelvic
    – colposcopy
    – speculum
  Physical Exam
Documentation Map
                  Physical Findings
Extragenital findings:
  •   Anterior neck region 35%
  •   Inner thighs 24%
  •   Facial 18%
  •   Breasts, posterior thorax, upper extremities,
      sacral and abdominal areas 12%

  source Charity Hospital, New Orleans 1994
             Physical Findings
Most common site and type of injury:
 •   Posterior fourchette (70%)
      - tears
 •   Labia minora (53%)
      - abrasions
 •   Hymenal tissue (29%)
      - ecchymosis
 •   Fossa Navicularis (25%)
      - tears
      source: San Luis Obispo, California 1991
Colposcope is a binocular system of
lenses of varying magnification coupled
with a light source to which a video
monitor, 35mm camera, is attached

Modify light intensity to allow for
changes in magnification.
•   Non-invasive
•   Superior to gross visualization
•   Subtle injuries are visualized
•   Documentation using photography
•   Standard of care
Forensic Evidence Collection
•   Forensic evidence collection is
•   Technological advances contribute to
    documentation of objective findings
•   Prosecution rests on objective data
           Timing of Evidence
•   Examine patient ASAP to minimize the loss of

•   72 hour limit for obtaining forensic evidence
    not absolute

•   May collect evidence up to 5-7 days following
    an assault
            Evidence Kits
    Evidence kits should contain:

•   Instruction checklist

•   Forms

•   Materials for collecting and preserving
          Evidence Collection
•   Collect the evidence from patients as
    guided by the forensic history, physical
    exam, and evidence collection kit

•   Reduce potential contamination

•   Distinguish patient’s DNA from suspect’s
        Evidence Collection
•   Oral swabs
•   Swabs obtained from the anal, cervix
    and vaginal areas
•   Body fluids found on other areas
•   Pubic and head hairs
•   Debris
•   Toxicology specimens
     Preservation of Evidence
Follow jurisdictional policies

•   Drying
•   Packaging
•   Labeling
•   Sealing
     Preservation of evidence
•   Secure storage sites

•   Law enforcement should transfer
    evidence from the exam site to the
    crime laboratory

•   Maintain chain of custody
         Laboratory Tests

• Pregnancy screening
• Toxicology specimens
• Hepatitis B, C and HIV antibody testing
  with consent
Do not test for: STD

•   Prophylactic STD treatment
•   Hepatitis B vaccine
•   Emergency Contraception
•   Follow-up labs/exam
    •   HIV and HCV antibody testing in 3 and 6
    •   Completion of HBV vaccination
Follow CDC recommendations for treatment of:
• Syphilis
• Chlamydia
• Gonorrhea

• Trichomonas

• Bacterial Vaginosis

• Hepatitis B

• HIV postexposure therapy
   Long Term Health Care
• Hepatitis B and/or C
• Pregnancy
• Suicidal thoughts/actions
    Follow-up Examination

•   Detect new infections
•   Complete hepatitis B immunization
•   Complete counseling and treatment for
    other STDs
•   Opportunity to monitor compliance
    with previous treatments

•   Only do physical evaluations if patient is
    symptomatic and has not been treated

•   Repeat serologic tests for Syphilis, HIV in 6
    weeks, 3 months, and 6 months
   Special Concerns in the
    Correctional Setting
Does reporting deter inmates from
seeking help?

What happens when reporting does
more harm than good?
     Impact of Sexual Assault
•   Inmates, Staff, Society
    – Inmates:
          – STI, Substance Abuse, Suicide, RTS, May themselves
            become perpetrators
          – Little control
          – Contradiction in culture and rules
    – Staff:
          –    Unmanageable Anger
          –    Secondary Trauma
          –    Guilt
          –    Powerless
     Impact of Sexual Assault
•   Impact on Society
    • Spread of STI
    • Financial Burden for Treatment
    • Survivors may become the Rapist
    • Substance Abuse
       The Impact of Being
Incarcerated and Being a Survivor
Feelings of disorientation and anxiousness may make people
unable to follow rules

Sharing or talking about feelings may be a safety risk for an

Isolation may be a relief but it could also cause further trauma
Increased anger may cause acting out

Complex nature of “consent” can lead to self-blame
– Protective pairing

Multiple traumas exacerbate symptoms
• Sexual assault is a violent crime
• Forensic evidence collection is
  challenging and prosecution rests on
  objective data
• Victim-centered approach recognizing
  the need for timely, compassionate,
  respectful and appropriate care is vital
•   Understanding the types and location of
    injuries is crucial
•   Understanding the emotional impact will
    facilitate emotional recovery
•   Documentation of accurate historical data
    and physical findings
•   Clear management and follow-up plans will
    follow standard of care and offer a
    comprehensive evaluation.