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S e x u a l V i o l e n c e
The following is an excerpt from the overview section of their handbook. For the full text go to: http://www.acep.org/1,2101,0.html?ext=.pdf or http://www.acep.org/library/pdf/sxa_handbook.pdf
Table of Contents: · Identification of sexual assault or sexual abuse · History · Additional pertinent history · Hospital Laboratory and Radiographic Data · Chain of Evidence/Chain of Custody
The evaluation of the sexually assaulted or abused patient is a challenge for health care professionals, particularly for the patient with developmental issues such as cognitive impairment or young age. Appropriate management of the patient requires a standardized clinical evaluation, an effective interface with law enforcement for the handling of forensic evidence, and coordination of the continuum of care with a community plan. Appropriate management of the sexually assaulted patient requires the clinician to address the medical and emotional needs of the patient while addressing the forensic requirements of the criminal justice system. Medical issues include acute injuries and evaluation of potential sexually transmitted disease and pregnancy. Emotional needs include acute crisis intervention and referral for appropriate follow-up counseling. Forensic tasks include thorough documentation of pertinent historical and physical findings, proper collection and handling of evidence, and presentation of findings and conclusions in court.
Development of a Community Response Plan Sexual assault is a serious societal problem that creates significant challenges to local communities as they attempt to create an overall plan for meeting the medical, emotional, physical safety, and legal needs of the patient. Well-planned multidisciplinary community response plans have been demonstrated to be cost effective while diminishing further harm to the patient and providing comprehensive care (Module– Societal Costs of Sexual Assault). Sexual assault response/resource teams (SARTs) have also enhanced public safety by increasing public awareness, increasing reporting, and facilitating investigation. Many different organizations and public agencies are crucial participants in an effective community-based sexual assault response plan. Key participants include, but are not limited to, medical and nursing personnel, patient advocates, college and school administrators, prosecutors, protective services personnel, law enforcement personnel, and forensic scientists (Module–Coordinated Community Response Plan). The SART creates a plan that addresses issues pertaining to the immediate response to sexual assault, but this is only the first step (Module–SART Development). Additional resources and planning for overall patient care, safety, and patient well-being are necessary. Each community will need to consider options that work best for their setting, geography, and local resources. At a minimum, professionals caring for sexual assault patients should be proficient in the core content of the evaluation and management of cases of sexual assault (Module–Core Content of Knowledge for Community Response Workers). The responsibilities and activities of each portion of the community plan should be clearly identified (Modules–Victim-Centered Responsibilities Matrix; Federal Funding and Violence Against Women Grant Information).
Identification of sexual assault or sexual abuse Identification of sexual assault is often difficult for many reasons. The sexually assaulted or abused patient often delays seeking medical evaluation due to feelings of shame, fear, or lack of understanding that they are victims of a crime. Delayed reporting may also result from the effect of drugs and/or alcohol ingested during a substance-facilitated sexual assault. Recent studies suggest that the majority of sexual assaults are perpetrated by acquaintances, not strangers, so emphasis must be given to documenting injuries that reflect lack of consent. Sexual assault by a person known to the patient tends to be underreported (Module–Issues of Sexual Assault by a Person Known to the Patient). Adults who are sexually assaulted may seek medical care out of fear of infection or pregnancy. Alternatively, the adult patient may have nonspecific symptoms, such as sleep disturbance, nightmares, emotional lability, fatigue, self-blame, shame, fear, or sexual dysfunction. Children who are sexually assaulted or abused may display variable nonspecific symptoms and/or physical findings. Children who are sexually abused most often delay reporting, do not willingly disclose the abuse, and if the incident is disclosed, facts are often incomplete or conflicting (Module–Pediatric/Adolescent Patient). Recent sexual assault is usually defined as within 72 hours. However, this interval may be extended as technology such as DNA analysis advances (Module–Forensic Laboratory Testing). Because some drugs can be found in the serum up to 1 week after ingestion, for the patient with drug-facilitated rape, the collection of evidence can be performed up to 96 hours. If the patient is in the out-of-hospital setting and the sexual assault is recent, the patient should be encouraged to go immediately to the emergency department, local rape crisis center, or other designated facility suitable for an evidentiary examination to collect physical evidence. The patient should be instructed to not engage in activities that may destroy important evidence that can be used to identify the perpetrator, such as urinating, defecating, vomiting, douching, removing/inserting a tampon, wiping/cleaning genital area, bathing, showering, gargling, brushing teeth, smoking, eating, drinking, chewing gum, changing clothes, or taking medications. Nonevidentiary examinations may or may not be emergent. Non-emergent cases may be referred to appropriate local resources for collection of appropriate evidence or for follow-up care once the patient's immediate needs are met. Clinical evaluation (ModulesPediatric/Adolescent Patient; and Adult/Adolescent Patient) Policies and procedures for the evaluation and management of the patient with the complaint of sexual assault should be established by all sexual assault evaluation facilities (Module–References). Sexual assault nurse examiner (SANE) programs are an excellent option for acute and chronic sexual assault evaluations, because they standardize the sexual assault evaluation and collection of evidence (Module– SANE Development and Operation Guide). Special attention and supervision must be provided if resident physicians are involved in sexual assault evaluations to best ensure timely, efficient, and standardized treatment. Standardized programs that include a competency assessment (reviewing local, legal, clinical, and follow-up issues) should be established in training institutions and should include a minimum number of supervised examinations (Module–Minimum Core Content). If present, life-threatening injuries must be treated first. The lack of physical injury does not necessarily indicate consensual sexual contact. Once stabilized, the patient should be placed into a private room as soon as possible. A specially trained individual who can provide crisis intervention, such as a rape crisis advocate, mental health professional, social worker, or pastoral caregiver, should be available for emotional support. If desired by the patient, a friend or relative may be present. Throughout the encounter, privacy, safety, and confidentiality must be ensured (Module–Confidentiality). Ideally, the information in the medical record should be available to outside authorities only with the consent of the patient. However, disclosure of the medical record may be mandated by law in some jurisdictions. In most states, the sexually assaulted patient is not required to report the assault to law enforcement authorities. In contrast, in many states, medical personnel are required by law to report all cases of sexual assault. Most states mandate the reporting of sexual abuse of children to police or to the child protection agency. However, in many jurisdictions, police coordinate and oversee the collection of evidence. Thus, if they determine that sexual assault has not occurred or if the patient is uncertain about pressing charges, no evidence is collected. · Medical evaluation and treatment · Reporting the crime · Performing a physical examination · Photodocumentation · Evidence collection: The patient has the right to decline the collection of any and all specimens. However, to give the patient the ability to make an informed decision, it is important to explain to the patient that this is the only time to gather certain forensic evidence · Transferal of evidence to law enforcement personnel In many jurisdictions, hospitals are not required by law to perform examinations on suspected perpetrators without a court order or alternative means of legally mandating such an examination. Persons placed under arrest do not have the right to refuse an examination for the collection of evidence if the officer has a court order. Because states vary in requirements, check your local statutes. In pediatric cases, check local and state laws regarding obtaining parental consent to provide treatment. In some states, if parental abuse is suspected (e.g., the child is brought by a child care worker or teacher) the examination may be performed without parental consent. Determination of consent to perform a sexual act is a legal principle and therefore not part of the assessment. One of the fundamental tenets of the forensic examination is objectivity. The goal of a forensic examination is to comprehensively and objectively document all findings.
Whenever possible, use open-ended (nonleading) questions and encourage free narrative. Special care is needed in obtaining the history of the pediatric patient (Module–Pediatric/Adolescent Patient). Document the following: 1. Specifics of the incident: Document direct quotes from the patient describing the incident a. Time, date, and place of the sexual assault or abuse b. The patient’s ability to give consent to the reported sexual activity c. Use of force, threats of force, weapons, coercion, or drugs and/or alcohol to facilitate sexual assault d. Types or means of assault e. The occurrence of penetration of any body part with a penis or other object f. Did the patient urinate, defecate, vomit, douche, remove/insert a tampon, wipe/clean the genital area, bathe, shower, gargle, brush teeth, smoke, eat, drink, chew gum, change clothes, or take medications after the incident? g. Did the patient bite the perpetrator, or was the patient bitten?
a. Allergies 3. Additional pertinent history
a. Use of contraceptives and what
type 4. Physical examination: The examiner should prevent cross-contamination of evidence by changing gloves whenever cross-contamination could occur. Clearly document all findings. 1. Before the patient undresses, place a clean hospital sheet on the floor to be a barrier for the collection paper (Module–Adult/Adolescent Patient). 2. Allow the patient to remove and place each piece of clothing being collected in a separate paper bag. Handle all clothing with gloved hands to prevent contamination of evidence (Module–Adult/Adolescent Patient). 3. Simultaneously identify the presence of any physical injury, biological evidence, or foreign debris, but do not disturb. 4. Recover any trace evidence, including sand, soil, leaves, grass, and biological secretions. Note the body location of the collection. Identify moist secretions. 5. Note all injuries by documenting the location, size, and complete description of any trauma, including bite marks, strangulation, or areas of point tenderness, especially those occurring around the mouth, breasts, thighs, wrists, upper arms, legs, back, and anogenital region (Module–Bite Mark Guidelines). 6. Perform appropriate photodocumentation of collection sites before collection, as well as of other suspect areas (Module–Medicolegal Photography in Sexual Assault). 7. Recover moist secretions with a dry swab. Look for areas of debris and dried secretions on the skin; flake them off onto folded paper. Recover any remaining material on these areas with a swab moistened with one drop of water (tap water is acceptable). 8. Document the Tanner Stage of the patient and describe the level of physical maturity (Module–Pediatric/Adolescent Patient). 9. Follow the sexual assault evidence collection instructions (Module–Adult/Adolescent Patient). Toluidine blue dye may be used to identify minor external genital and anal injuries, but it may cause discomfort (burning) in prepubertal children (Module–Use of Toluidine Blue). When the vaginal examination is performed, the speculum should be lubricated with tap water because other lubricants may affect test results and decrease sperm motility. A vaginal speculum is never used in prepubertal children without general anesthesia. When drug/alcohol-facilitated sexual assault is suspected, blood and/or urine should be collected. If alcohol was ingested, use the law enforcement blood alcohol collection kit or collect three fluoride (gray top) tubes. Check with local law enforcement for the kit. If a drug was ingested within 36 hours of examination, collect three full fluoride (gray top) tubes of blood and 100 ml of nonprepped, first-void urine. If a drug was ingested more than 36 hours before the examination, collect 100 ml of nonprepped, first-void urine. Do NOT place urine or blood in the sexual assault kit. Package each item separately, label and seal, and initial each package. A colposcope may be used as an adjunctive examination tool. Anogenital examination findings are enhanced through illumination, magnification, and photodocumentation (Module–Use of Colposcope). The collection of known samples (standards) from the patient may be indicated (buccal, smear, blood, or hair). Depending on laboratory preferences, these samples can be Hospital Laboratory and Radiographic Data Consider tests that are appropriate for a given patient: 1. Serum or urine pregnancy test. 2. Cultures and syphilis testing: In cases where prophylaxis will be given and chronic abuse is not suspected, cultures and syphilis testing are not necessary. This area is very controversial (Module–Adult/Adolescent Patient). 3. Hepatitis B surface antibody: To check for the immune status in the previously immunized patient. Hepatitis B testing is not indicated in the nonimmunized patient (Module–Sexually Transmitted Disease in Adult and Child Patients Who Have Been Sexually Assaulted/Abused). 4. Laboratory and radiographic studies as indicated. 5. HIV counseling and follow-up testing (Module–Human Immunodeficiency Virus). Referral is strongly encouraged. Patients may be referred to a center that provides confidential counseling and testing or to the primary care provider within 72 hours of the exposure to establish the HIV status at the time of the assault or abuse. Chain of Evidence/Chain of Custody Note: If the urine sample is not officially part of the rape kit, take special caution to maintain the chain of evidence. Document all historical and physical findings. Properly seal and initial all specimens and label with:
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Hospital name, patient name, and
patient identification number All transfers of custody of evidence must be accountable by keeping a written record of:
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Name and signature of the person
receiving the evidence Consider offering the following interventions depending on the circumstances: 1. Antibiotic prophylaxis for sexually transmitted diseases (Modules–Sexually Transmitted Disease in Adult and Child Patients Who Have Been Sexually Assaulted/Abused; and Pediatric/Adolescent Patient). 2. Hepatitis B immunization is indicated if the patient has not been previously immunized (Modules–Sexually Transmitted Disease in Adult and Child Patients Who Have Been Sexually Assaulted/Abused; and Pediatric/Adolescent Patient). 3. HIV prophylaxis based on risk assessment of exposure (Module–Human Immunodeficiency Virus) 4. Pregnancy prevention (Module–Emergency Pregnancy Prophylaxis). 1. The patient should be given referrals to local resources for follow-up counseling and advocate services (Module–State Sexual Assault Coalitions). 2. The patient should be referred for follow-up examinations in 2 weeks, 3 months, and 6 months for evaluation of pregnancy and sexually transmitted diseases (Module–Sexually Transmitted Disease in Adult and Child Patients Who Have Been Sexually Assaulted/Abused). 3. Provide written documentation to the patient of tests performed, treatment received, followup appointments, community resources, and what to expect in terms of test results and the legal process. |
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