The approach to managing the sexually assaulted victim

Praveen Indraratna





What is Sexual Assault?

  • Penetration of the vulva or anus by a penis or other object OR
  • Penetration of the mouth by a penis AND
  • Without consent

Note that the specific management of sexual assault varies slightly on a state-by-state basis, here is a general approach.

Role of the Doctor

This is a challenging clinical scenario for doctors in the Emergency Department. The police may often be involved and may bring the victim in, or he/she may present voluntarily without any police contact.

The role of the clinician comprises:

  • Empathy, reassurance and emotional support of the traumatised victim. This may be particularly difficult if you are a male practitioner. Contact your nearest Sexual Assault Service to discuss with the on-call counsellor.
  • Protection against medical consequences of sexual assault such as sexually transmitted infections (STIs) and pregnancy.
  • Encouraging the victim to report the assault to the police, so that a forensic medical examination with collection of DNA can be carried out.

Involvement of the Police

Remember, often the argument is not over whether intercourse occurred, but rather whether consent was obtained.

Before you begin the history, ask the victim if he/she has contacted the police and whether they would like you to do so on their behalf. If they are unsure, contact the police and inform the victim that complaints can be withdrawn later. Ask if anyone else knows about the assault.

It is the job of the police, not yours, to ask questions to identify the perpetrator, and if the victim has provided this information to the police, it is important to contact them and read any statements.

If the victim is under the age of 16, it is MANDATORY to report.

Before you begin the history

  • Ensure the victim’s safety and privacy
  • Do not be judgmental – that is the job of the police
  • Explain that the victim’s current emotions are normal for the situation

History

  • When did it happen?
    • Vaginal swabs will not yield much DNA after 72 hours, anal and oral swabs are most effective within the first 24 hours. Note that DNA can last for years on clothes or bedding.
    • Ask whether the victim has changed clothes, brushed their teeth or showered since the assault – this will affect DNA retrieval.
    • What did the attacker use – penis, other body part, other object?
      • Did ejaculation occur?
      • Where was it used – vulva, vagina, mouth, rectum?
      • In the last seven days, have you had intercourse with anyone else?
        • DNA of a consensual sexual partner may be found on examination
        • Before the assault, did you feel as if you were drugged at any point? Is there a possibility your drink was spiked? If so, consider testing for drug metabolites.

It is crucial to document all this information in case legal proceedings take place.

The Examination

General Examination

Perform a general inspection of the victim, with a chaperone if necessary.

  • Sit the victim on the edge of the bed – this is less imposing than if he/she was supine
  • Look for evidence of trauma to the rest of the body e.g. strangulation marks.
  • You may photograph this with the victim’s permission, but do so in a way that identifies the location and size of any bruise or lesion (using an orientation shot or a ruler in the photo). Do NOT photograph genital lesions.

Forensic Examination

This is carried out:

  • Only if the victim wants to, or is unsure whether to involve the police
  • By a qualified person from a sexual assault unit (some exceptions in remote communities)

Explain to the patient the purpose of the forensic examination, and obtain consent for the examination and to release information for legal proceedings.

If the victim is younger than 14, contact a Child Protection Unit as video colposcopy will need to be performed.

Procedure for Forensic Examination – to be performed by a forensic clinician

  • If the victim is in the same clothes since the assault occurred, ask her to change into a gown over a ‘drop-sheet.’ This is a paper sheet onto which hair or other samples of the perpetrator will collect. Clothes should be stored in paper bags and handed to police
  • Inspect the genitalia for traumatic injury – often this is not found, but should be looked for. You need to know whether the victim is sexually active and whether she has had children, as this affects the normal appearance of the genitalia.
    • The posterior fourchette is the most common location for injuries
    • Multiple injuries are more suggestive of sexual assault
    • DNA swabs – these should be performed by a forensic clinician, using a proper Sexual Offences Investigation Kit and not be self collected. You will know from the history where to take swabs from. Note that victims may object to the use of a speculum.
    • Common locations of swabs include:
      • High vaginal swab
      • Low vaginal swab
      • Endocervical swab (if the assault occurred over 24 hours ago).
      • Oral swab – taken from just behind the lower anterior teeth
      • Anorectal swab
      • Take reference DNA from the buccal mucosa so that the victim’s own DNA is on record
      • The swabs are handed to police for analysis in a police laboratory. Hospital laboratories cannot be used for this purpose.

Investigations

As the hospital clinician, you should order the following:

  • Hepatitis B serology – is the victim immune or not?
  • Blood and urine toxicology if indicated by the history, or if the victim appears to be under the influence of a substance
  • STI screening is controversial, and you should follow local protocols or ask for senior advice.

 

Management

  • Emotional support. The victim should be referred for counselling.
  • Victim safety – organise emergency accommodation if the victim will be unsafe at home
  • STI prophylaxis
    • 2x500mg azithromycin tablets  – to cover chlamydia
    • 250mg IM ceftriaxone – to cover gonorrhoea
    • Hepatitis B vaccine if non-immune
    • Post-exposure HIV prophylaxis is NOT cost effective in most circumstances, but consult your immunology registrar for advice
    • You may advise the patient to follow up at 2 weeks and 3 months for repeat testing to allow for incubation periods, however, be aware that many patients will not attend follow up appointments.
    • Emergency contraception – regardless of menstrual cycle timing
      • Postinor-2 (750 micrograms levonorgesterel)

Conclusion

The clinician has a number of roles in the management of sexual assault, and by doing so in a non-judgemental, empathetic manner; both medical and emotional complications of the assault can be managed.

The forensic examination needs to be performed by an experienced forensic clinician, and the DNA evidence obtained from here can be used to identify the perpetrator.

For a list of sexual assault services in Australia click here

http://www.livingwell.org.au/Counsellingandsupport/Australiawidesexualassaultservices.aspx

 

Acknowledgement

Dr Alanah Houston for her review of this blog entry

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