Care for the Sexual Assault Survivor

Sexual assault is a crime of violence. The precise definition varies from state to state, but it always includes varying degrees of nonconsenting sexual activity. It is characterized by the use of force, physical threat, or the abuse of authority. Consent cannot be given when a person uses force, threat of force, coercion, or when the victim is asleep, incapacitated, or unconscious. Sexual assault includes rape (forced vaginal penetration), nonconsensual sodomy (anal or oral penetration), unwanted sexual contact or fondling, or attempts to commit these acts. It can occur without regard to gender or relationship (e.g., within a marriage).

In the United States, one in six women and one in 33 men will be sexually assaulted in their lifetime. There were 89,000 forcible rapes in the United States in 2008 – a rate of 57/100,000 women.¹  This represents a decrease of 1.6% from the previous year and the lowest figure in 20 years.²  Although this likely represents a true decrease in the number of rapes across the country, we must remember that rape is one of the most underreported crimes, with males the least likely to report.¹  Sixty percent of sexual assaults are not reported to law enforcement, even though reporting has increased by one third since 1993.¹  Fear of the rapist, embarrassment, and not considering their rape a crime or police matter are the primary reasons women choose not to report.³ Contrary to popular assumptions and depictions in the media, approximately two thirds of rapists are known to their victims.⁴  Perpetrators of sexual violence are not distinguished by race/ethnicity or socioeconomic status. 

As a novel method to address the needs of sexual assault survivors, Sexual Assault Response Teams (SART) combined with Sexual Assault Nurse Examiners (SANE) were founded in 1977. There are now over 300 SANE/SART programs across the United States. A SANE is a registered or advanced practice nurse who has been specially trained to provide comprehensive care to the sexual assault victim. The training consists of 40 hours of didactic class work and a 40–60 hour mentored practical experience. These nurses provide first response care in a variety of settings. Approximately 75% are hospital based, the rest are based in community health clinics, rape crisis centers, or free standing community sites.

The goals of care provided by the SANE are documentation and care of injuries, forensic medical evidence collection, evaluation of risk and prophylactic treatment of sexually transmitted infections, evaluation of risk of pregnancy and prophylactic treatment, crisis intervention, and the support of psychological needs. In addition to these major goals, SANE serve on SART and provide expert witness testimony in the courtroom. SANE can alter the traditional emergency department experience by reducing wait times and exam times. They strive to preserve their patient’s dignity, ensure that victims are not re-traumatized by the evidentiary exam, and assist victims in gaining control by allowing survivors to make decisions throughout the evidence collecting process.⁵

The SART is a group of professionals whose goal is to provide a coordinated community response to victims of sexual assault. The team is most often comprised of the SANE or other first response medical care provider, the victim advocate, and law enforcement. Other team members can include the prosecuting attorney, community government officials, representatives of local school/university systems, or any other invested community personnel. As part of the SART, the role of the advocate is to work directly with the survivor; to explain their rights both medical and legal, and to inform them of what to expect from the medical and legal systems. They provide emotional support and information and connect survivors to counseling and support groups after the immediate crisis is over. They can help the survivor develop a plan of action, keeping in mind that not all survivors want or need the same services. They can also provide support throughout the legal process if the survivor decides to pursue relief through the criminal justice system.⁴ The SART provides a victim sensitive solution to systemic gaps in the medical/legal response to those who have experienced sexual assault. In some cases, care is provided to the victim as a group, but most frequently members of the team provide care individually and have set meeting times to discuss cases, and trouble shoot the system. This provides the checks and balances necessary to ensure the care received is survivor focused, thorough, and compassionate.

Even in communities and health care systems that lack a formal SANE/SART program, the goals and philosophies of SANE/SART can still provide the basis for how best to treat sexual assault survivor.

The survivor may present for care in a variety of ways, including directly to the emergency department, the police department, health care clinic, or advocacy center. Close communication among the sites is important to ensure a cohesive response to the survivor. By conveying an atmosphere of calm acceptance during the initial contact there is an immediate beginning of the healing process.

Upon presentation to the site of care, whether it be a busy emergency department or small clinic or rape crisis center, the patient should be escorted to a quiet, private area. Triage of the survivor patient is of the highest priority. Optimally, the exam should be initiated within an hour of arrival. If there are serious or life-threatening emergencies, these should be attended to first, although evidence collection can occur simultaneously if possible and desired, such as in the operating room.

Using the team approach to care necessitates the presence of an advocate. An advocate can be contacted at the same time as the SANE or other health care provider.

There is often confusion about access to treatment requiring a medical forensic exam (MFE).⁶ The possible components of care should be clarified for the patient, i.e. medical screening exam for injury, prophylactic treatment of sexually transmitted infections (STI), pregnancy prevention, and a MFE, and how receiving one is not dependent on another. At any time, the process can be stopped entirely or altered to meet individual needs. For example, a woman presenting with the complaint of sexual assault can initially request an entire medical evidence exam, but after experiencing the initial steps can change her mind to allow only partial evidence collection and STI prevention. Decisions should be supported to assist in the resumption of personal control over both mind and body.

The Violence Against Women Act of 2005 states that states and territories may not, “require a victim of sexual assault to participate in the criminal justice system or cooperate with law enforcement in order to be provided with a forensic medical exam, reimbursed for charges incurred on account of such exam, or both.” This act requires access to an exam free or fully reimbursed, regardless of whether the victim reports to law enforcement or cooperates with the criminal justice system. Practically, the effect of this law is to allow survivors time to decide whether to pursue their case. It encourages them to seek evidence collection and treatment quickly without the immediate pressure of difficult decision making directly after such a traumatic experience. This law does not mandate anonymity, although some states offer a “Jane Doe” rape kit voluntarily, nor does it interfere with the mandatory reporting laws of states that have them.

When obtaining informed consent the process and components of the examination should be described. Individuals should be provided with the state’s reporting requirements, a simplified version of the Violence Against Women Act of 2005, and the option to opt out of any portion of the exam or MFE at any point during the procedures.

Whenever possible a female health care provider should be chosen to take a history and carry out the examination. Although thoughtful, compassionate care is possible regardless of the gender of staff, there is a distinct preference by patients for a female provider. In an evaluation in the United Kingdom, three quarters of patients, both male and female, preferred a female provider. While 100% said they would continue the exam if the provider was a woman, almost half, 43.5% said they would not if the provider was a male.⁷

Forensic evidence is usually collected up to 72 hours after the assault, but may be extended up to 96 hours in some cases and facilities depending on injuries and policies. Post-assault care can be offered well beyond the time limited forensic collection as it is never too late to examine for injuries and provide referrals for psychological counseling.

After the survivor has decided to proceed and consent is obtained, it should be ascertained whether she has ingested food or drink since the assault. If not, which is the ideal, the evidence collection should begin with the oral specimens, so that water may be offered. Additionally, if the survivor has to urinate, a specimen should be collected and patting dry with toilet tissue, not wiping, should be recommended. The toilet tissue may be saved and sent to the crime lab with the kit. This may also be done upon arrival to the site to avoid any period of time without liquids or the discomfort of a full bladder.

Clothing, if worn during/after the assault should be collected and placed in paper, not plastic, bags and sent to the crime lab. Clothing should be collected one article at a time and placed in separate bags. Sweat suits or other appropriate replacement clothing can be provided to the survivor following the exam. Many local organizations provide clothing kits for survivors including clothing, undergarments, and toiletries. 

The medical screening exam and forensic evidence collection can occur concurrently. The exam should be performed beginning head to toe, least invasive to most invasive. Explain the necessity of a close visual inspection of the body to look for bruises, scratches, bite marks, etc.  Record size and appearance of injuries; noting tears or tenderness, ecchymosis, abrasions, redness, or swelling (TEARS). Photograph injuries, labeling them with date, time, and identifying information.

At any point in the examination, dried and/or moist secretions and foreign materials may be collected and placed in labeled envelopes, noting from where the specimen was obtained. Sterile water may be used to assist with the collection of dry secretions. A Wood’s Lamp or other alternate light source can be helpful to identify areas from which to sample.

As frequently as possible, the patient can participate in specimen collection. This can aid in the recovery process by helping the patient regain control over his/her own body. Specimens for easy self collection include hair combing and pulling and the oral swabs and buccal smear.

Head hair combings are obtained using the comb and towel provided in the collection kit. The towel can be placed either around the shoulders or in front of the patient and the hair can be combed over it. The purpose of this system is to collect any foreign debris that may be stuck in the hair. The towel is folded with the debris and comb inside and placed back in the kit. If matted hair is found it is cut out and placed in a separate envelope. Twelve head hairs are then pulled, including the root, from various areas on the head and also placed in a separate envelope.

The oral cavity is swabbed with four swabs concentrating on the inside upper and lower lips along the gum lines and under the tongue. These are then smeared on a glass slide and allowed to dry before placing them in an envelope. A buccal smear DNA sample can be also taken at this time. 

Pubic hair, if present, is combed and pulled in a similar fashion as the head hair, but the towel is placed under the buttocks before the combing proceeds. If the patient is having difficulty pulling either the head or pubic hair, wearing a glove can often assist with the ability to grasp the hair.

The external genitalia can be examined with direct visualization, toluidine blue, an alternate light source, and/or colposcope. Make sure to include the inner thighs and perianal area when looking for injury. Some of the most common areas of injury are labia minora, posterior fourchette, fossa navicularis. The most common type of injury are lacerations and/or bruising.⁸ Although rates of injury after consensual intercourse range from 10 to 75%,⁹ which therefore makes it not possible to be certain an injury obtained is from a sexual assault, it is nonetheless important to document them for potential future prosecutorial action. A nonlubricated speculum moistened with sterile water may be used to examine for internal vaginal/cervical injuries at which time four vaginal and cervical swabs are taken and slides made similarly to the oral swabs. Some recommend a swab from the cervical os.⁶ Swabs or a sterile gauze pad can be used to collect a specimen from the perianal area.

For male patients the genitalia is also inspected closely for any injuries or secretions. A total of four swabs are taken from the glans, shaft, scrotum, and perianal area; two at a time and slides are made. The swabs may be moistened with sterile water to aid collection.

The anus and rectum are examined by direct visualization and/or colposcope. An anoscope and toluidine blue dye can also be used, especially in cases where there has been rectal penetration. Inspect the buttocks, perianal skin, and anal folds for injury. It is often easier to perform a thorough inspection with the patient in the knee chest position. Place hands on each side of the buttocks and separate. Allow the rectal orifice to relax before inspection or use of the anoscope. Four swabs are taken from the rectum and slides prepared.

Before closing and signing the kit, make sure all swabs are dry before they are placed in their appropriate envelopes, all envelopes labeled and signed, and all slides are labeled and in the kit. If a plastic speculum or anoscope was used, they also may be included in the kit. The kit is sealed with tamper proof seals and signed as the chain of evidence must be maintained. Make copies of the documentation tool used; one each for the medical record, law enforcement, and in the evidence collection kit.

There is no consensus about what does and does not constitute a drug facilitated sexual assault which results in confusion when interpreting statistics and evaluating and testing for it during the MFE. The widespread detection of alcohol and/or drugs in urine or blood of sexual assault survivors does not tell us whether the ingestion was voluntary or involuntary. It has been estimated that about 2% of alleged drug facilitated sexual assault result from involuntary ingestion of substances.^{10, 11} Voluntary consumption can also lower inhibitions and affect judgments which can contribute to susceptibility to assault or render the victim unable to give consent to any sexual activity.¹²

Discuss with local law enforcement and prosecutors which substance to test for and where the testing should be done. Most substances, particularly alcohol and gammyhydroxibuterate (GHB) are metabolized quickly, so specimens for testing should be collected as quickly as possible.

Sexually transmitted infections and prophylaxis

Trichomoniasis, bacterial vaginosis, gonorrhea, and chlamydia are the most frequently diagnosed infections after a sexual assault.¹³ The option for prophylactic treatment is a crucial component of the provision of postassault care. The decision to test for STIs is made on a case by case basis. In our practice, we test only if prophylactic treatment is declined, in which case follow-up testing is recommended in 1–2 weeks. Testing for syphilis and HIV in 6 weeks, 3 months, and 6 months postassault is recommended to all survivors.

Prophylactic treatment follows the CDC guidelines for STIs. A pregnancy test should be done prior to administration of any medication. Subsequent to the publication of the 2006 guidelines, cefixime in tablet form has become available in the Unites States. This may be used as a first line gonorrhea treatment instead of ceftriaxone to provide for oral treatments only. It is our goal to provide oral treatment only, with the entire course of treatment complete before leaving the facility. We provide:

Cefixime 400 mg p.o. plus

Metronidazole 2 g p.o. plus

Azithromycin 1 g p.o.

Preceded by promethazine 25 mg p.o. 30 min prior to prevent nausea and/or vomiting. 

Consult the CDC guidelines for treatment recommendations for those that require alternate treatments. The first hepatitis B vaccine can be administered to those not previously immunized with instructions to complete the series in 1–2 months and 4–6 months after the first dose. Additionally, tetanus toxoid is administered when appropriate.

Pregnancy prophylaxis

If not currently pregnant or using a reliable birth control method, pregnancy prophylaxis is offered. Plan B is the most effective pill form of prophylaxis with the least number of side effects. The Yuzpe method continues to be a viable alternative. Both pills may be taken simultaneously. A newer formulation of Plan B is available in some areas where the entire dose is one pill. Plan B is 89% effective when used within 72 hours but may be used for up to 120 hours postassault. A Paragard IUC also may be used. It can be inserted up to 5–7 days postassault and is 99.9% effective.

HIV prophylaxis

There are limited data establishing the efficacy of postexposure prophylaxis (PEP) after a sexual assault. The use of PEP postsexual assault is based on the recommendation for health care workers postoccupational exposure. There are many factors that increase the HIV transmission risk to take into consideration before the decision to use PEP is made: the prevalence of HIV in the community where the assault took place, whether anal or vaginal penetration occurred, multiple assailants, multiple penetrations, the presence of nonintact skin, etc. An immediate consult with a HIV specialist should be facilitated if at all possible. If a discussion of the risks and benefits results in the patient’s desire to begin PEP, it should be initiated as soon as possible. A 3–5 day supply of zidovudine is given and appointments made with an infectious disease specialist to continue treatment and follow-up care.¹³

After completion of the MFE and the provision of any prophylactic treatments, referrals are made for the continuation of care. This can include medical care referrals for ongoing STI testing, continued HIV prophylaxis, and follow-up treatment for injuries if necessary. The provider should also make a referral for psychological care to address the common sequelae of sexual assault, including depression and post-traumatic stress disorder (PTSD). Psychological counseling can help ameliorate long-term consequences postsexual assault.

A sexual assault victim is both a patient and the victim of a crime. This second category may therefore involve both the victim and any health care provider in the criminal justice system. Indeed, many if not all states’ versions of the “gun and knife” statute (see, e.g., Michigan Compiled Laws § 750.411) require that a health care provider contact police upon presentation of any victim of any crime of violence. Many of the recommended protocols, from handling samples and specimens to recording a full history, are created at least partially out of the possibility that these items will have future value as forensic evidence. A rape victim who receives empathic and professional attention from a health care provider is more likely to have the wherewithal to participate in the criminal justice system.

Testifying in court

If criminal charges are brought, a health care provider may find herself testifying in court in a number of different capacities. Depending on the state, various witnesses may be called at a preliminary hearing, an evidentiary hearing or at a jury trial. However, the majority of criminal cases are resolved without the need for any formal testimony. In fact, the more thoroughly and accurately a rape kit is completed, the less likely a health care provider will have to come to court to testify at all. When health care provider testimony is required, it can range from the simple recitation of facts (“I took her underwear, placed them in a paper bag, and handed the paper bag to a police officer” or “I took this photograph at this time and place”) to a detailed recap of the victim’s history to the rendering of an opinion concerning the consistency or lack thereof between the patient’s history and the provider’s physical observations.

Given the traumatized emotional state of many sexual assault survivors it is often the health care provider’s testimony that most accurately presents the salient facts to a jury. The type of testimony required will vary by state and changes constantly due to the development of caselaw from the United States Supreme Court and caselaw from state courts.

If a prosecutor or defense attorney wants to present the testimony of a health care provider in court, the provider will be generally receive a subpoena. It is often wise to contact the prosecutor, the police officer, or the defense attorney upon receiving a subpoena. The health care provider can usually be provided with the nature of the information about which she will be asked in court. For example, if the defense is “I didn’t do it,” the provider’s testimony may focus on straightforward observations of injuries or which swabs were taken from where. If the defense is “she consented” some courts may permit providers to testify to their opinions regarding the nature and location of injuries. Conscientious, plain-speaking witnesses regularly get the better of obnoxious lawyers solely by virtue of their calm, accurate testimony. Regardless of who is asking questions, listen carefully to the question and answer only the question asked. Also listen carefully to your own answers – they are often woven into future questions with subtle changes that, if not corrected by you, may serve to undermine your own testimony.