gynecology and obstetrics
Medical Examination of the Rape Victim
Evaluation of the Rape Victim
Goals of medical evaluation after rape are Medical assessment and treatment of injuries and assessment, treatment, and prevention of pregnancy and STIs Collection of forensic evidence Psychologic evaluation Recommendation of crisis intervention and psychologic support If patients seek advice before medical evaluation, they are told not to throw out or change clothing, wash, shower, douche, brush their teeth, clip their fingernails, or use mouthwash; doing so may destroy evidence. Whenever possible, all people who are raped are referred to a local rape center, often a hospital emergency department; such centers are staffed by specially trained practitioners (eg, sexual assault nurse examiners [SANE]). Some areas in the US have a sexual assault response team (SART), which includes members from health care, forensics, the local rape crisis center, law enforcement, and the prosecutor's office. Benefits of a rape evaluation are explained, but patients are free to consent to or decline the evaluation. The police are notified if patients consent. Most patients are greatly traumatized, and their care requires sensitivity, empathy, and compassion. Patients may feel more comfortable with a clinician of the same sex; all patients should be asked about their preference before the examination. A female staff member should accompany all males evaluating a female. Patients are provided privacy and quiet whenever possible. A form (sometimes part of a rape evidence collection kit) is used to record legal evidence and medical findings (for typical elements in the form, see table Typical Examination for Alleged Rape ); it should be adapted to local requirements. Because the medical record may be used in court, results should be written legibly and in nontechnical language that can be understood by a jury. Before beginning, the examiner asks the patient’s permission. Because recounting the events often frightens or embarrasses the patient, the examiner must be reassuring, empathetic, and nonjudgmental and should not rush the patient. Privacy should be ensured. The examiner elicits specific details, including Type of injuries sustained (particularly to the mouth, breasts, vagina, and rectum) Any bleeding from or abrasions on the patient or assailant (to help assess the risk of transmission of HIV and hepatitis) Description of the attack (eg, which orifices were penetrated, whether ejaculation occurred or a condom was used) Assailant’s use of aggression, threats, weapons, and violent behavior Description of the assailant Many rape reporting forms include most or all of these questions (see table Typical Examination for Alleged Rape ). The patient should be told why questions are being asked (eg, information about contraceptive use helps determine risk of pregnancy after rape; information about previous coitus helps determine validity of sperm testing). The examination should be explained before each step; the patient may refuse any part of the examination. Results should be reviewed with the patient. When feasible, photographs of possible injuries are taken. The mouth, breasts, genitals, and rectum are examined closely. Common sites of injury in females include the labia minora and posterior vagina. Examination using a Wood’s lamp may detect semen or foreign debris on the skin. Colposcopy is particularly sensitive for subtle genital injuries. Some colposcopes have cameras attached, making it possible to detect and photograph injuries simultaneously. Whether use of toluidine blue to highlight areas of injury is accepted as evidence varies by jurisdiction. Routine testing includes a pregnancy test and serologic tests for syphilis, hepatitis B, and HIV; if done within a few hours of rape, these tests provide information about pregnancy or infections present before the rape but not those that develop after the rape. Vaginal secretions or urine is tested for trichomonal vaginitis and bacterial vaginosis; samples from every penetrated orifice (vaginal, oral, or rectal) are obtained for gonorrheal and chlamydial testing ( Evaluation reference ). Patients may decline STI testing, possibly because empiric therapy is typically given to all patients. Follow-up tests are done to check for pregnancy and STIs: At 1 week: Gonorrhea, chlamydial infection, and trichomoniasis in patients who refused prophylactic treatment At 2 weeks: Pregnancy At 4 to 6 weeks: Syphilis and HIV infection At 3 months: Syphilis, hepatitis, and HIV infection If the patient has amnesia for events around the time of rape, drug screening for flunitrazepam (the date rape drug) and gamma hydroxybutyrate should be considered. Testing for drugs of abuse and alcohol is controversial because evidence of intoxication may be used to discredit the patient. Patients with severe lacerations of the upper vagina, especially children, may require laparoscopy to determine depth of the injury. Evidence that can provide proof of rape is collected (see table Typical Examination for Alleged Rape ); it typically includes Clothing Smears of the buccal, vaginal, and rectal mucosa Combed samples of scalp and pubic hair as well as control samples (pulled from the patient) Fingernail clippings and scrapings Blood and saliva samples If available, semen Many types of evidence collection kits are available commercially, and some states recommend specific kits. Evidence is often absent or inconclusive after showering, changing clothes, or activities that involve sites of penetration, such as douching. Evidence becomes weaker or disappears as time passes, particularly after>36 hours; however, depending on the jurisdiction, evidence may be collected up to 7 days after rape. A chain of custody, in which evidence is in the possession of an identified person at all times, must be maintained. Thus, specimens are placed in individual packages, labeled, dated, sealed, and held until delivery to another person (typically, law enforcement or laboratory personnel), who signs a receipt. In some jurisdictions, samples for DNA testing to identify the assailant are collected. Clinicians should encourage patients to seek help with managing the effects of their trauma and with restoring their ability to function (crisis intervention) and to seek psychologic support. 