Sexual Assault Author: Carolyn J. Sachs, MD, MPH
Editorial changes - 2009-11-04
Author information and module status
Prevention
Screening
Diagnosis
Consultation for Diagnosis
Hospitalization
Non-drug Therapy
Drug Therapy
Patient Education
Consultation for Management
Follow-up
Tables
Figures
References
Glossary
What's New
Patient Information
Additional Resources
Tools
Diagnosis
  • Ask patients who have certain chief complaints about recent sexual assault.
  • Determine the capacity of the patient to consent to a forensic examination.
  • Address psychosocial issues related to the examination itself before doing a diagnostic physical exam.
  • Perform a complete physical examination, looking for injury and potential evidence.
  • Perform a careful and detailed anogenital examination for the diagnosis of injury.
  • Obtain standard forensic specimens during inspection of the mouth, body, external genitalia, rectum, vagina, and cervix.
  • Collect samples to test for sexually transmitted diseases that are not completely treated after the assault.
  • Collect blood, buccal, and urine specimens for crime lab testing for DNA reference, pregnancy, and toxicology analysis if indicated.
History and Physical Examination Elements for Sexual Assault (table)
Laboratory and Other Studies for Sexual Assault (table)
Differential Diagnosis table not applicable to this module

Ask patients who have certain chief complaints about recent sexual assault. B

  • When patients have a chief complaint of sexual assault, proceed with suggested history and physical examination.
  • When patients have other chief complaints that have the potential to be related to sexual assault, ask patients with:
    • Complaints related to sexual activity if the related activity was consensual or not
    • Genital or rectal pain or suspicious episodes of loss of consciousness about the possibility of sexual assault
    • Extreme anxiety and fear regarding a pelvic or genital exam
    • Depression, anxiety, suicidality, or unexplained somatic symptoms or pain about a history of past sexual assault
    • A history of intimate partner violence about sexual activity done without consent or through coercive methods
  • See table History and Physical Examination Elements for Sexual Assault.
Background | Back to top


Determine the capacity of the patient to consent to a forensic examination. C

  • When taking the diagnostic history, observe the patient's ability to understand and respond appropriately to questions.
  • If the patient lacks the ability to consent due to drugs or alcohol, defer the examination until the patient regains the ability to consent to examination.
  • See table History and Physical Examination Elements for Sexual Assault.
Background | Back to top


Address psychosocial issues related to the examination itself before doing a diagnostic physical exam. B

  • Encourage patients to communicate any discomfort or questions to the examiner and to ask for a break from the exam if needed.
  • Inform patients of their right to decline any portion of the exam and the ability to stop the exam at any point.
  • Offer patients the opportunity to have a family member, friend, or patient advocate in the room during all parts of the examination.
  • See table History and Physical Examination Elements for Sexual Assault.
Background | Back to top


Perform a complete physical examination, looking for injury and potential evidence. BC

  • Become familiar with local forms and instructions before being called upon to do a sexual assault exam.
  • Wear gloves throughout the entire evidence collection process.
  • Examine the patient's oral cavity and entire body for signs of trauma and foreign material.
  • Document injury found anywhere on the body, using words and photography.
  • Use a Wood's lamp or alternative light source in a dark room to search for semen on the patient's body in appropriate cases.
  • See table History and Physical Examination Elements for Sexual Assault.
Background | Back to top


Perform a careful and detailed anogenital examination for the diagnosis of injury. B

  • Examine:
    • Patient's thighs and perineum for signs of trauma and for foreign materials, such as seminal stains
    • Perineal, penile, and scrotal folds on the male to look for injury
    • Perineum and labia (majora and minora) on the female to look for injury
  • In female patients:
    • Perform labial traction to look for injury to the posterior fourchette and hymen by gently pulling outward on the labia majora
    • Examine the entire perimeter of the hymen using a moistened swab or an inflated Foley catheter in patients for which hymenal injury is possible and the hymen is redundant and cannot be seen with simple traction
  • Immediately refer patients with gross deformities or extensive hemorrhage for evaluation by a urologist (male patients) or a gynecologist (female patients).
  • Use available colposcopy or magnification source with photo or video attachments to detect and document injury.
  • Use toluidine blue dye if available to enhance the documentation of injury:
    • Apply a 1% aqueous solution of toluidine blue dye to the perineum and wipe off excess dye with a cotton ball moistened with lubricating jelly
    • In females apply the dye before speculum exam to eliminate the possibility of iatrogenic injury
    • In males and females apply the dye before anoscopic exam to eliminate the possibility of iatrogenic injury
  • Perform anoscopy to detect internal injury when indicated by history examination in the same manner as diagnostic anoscopy used to search for hemorrhoids or fissures in common practice.
  • See table History and Physical Examination Elements for Sexual Assault.
  • See figure Separation of Labia.
  • See figure Labial Traction.
  • See figure Examination of the Hymen.
  • See figure Anoscopic Detection of Injury.
  • See figure Colposcope.
Background | Back to top


Obtain standard forensic specimens during inspection of the mouth, body, external genitalia, rectum, vagina, and cervix. B

  • If not already collected by law enforcement, collect the clothes that the patient wore during the assault for potential evidence:
    • Instruct the patient to disrobe by dropping clothes onto a clean sheet
    • Using gloved hands, place each article of clothing in a separate paper bag
    • Collect the sheet and any material that might have fallen while the patient disrobed and place in a separate paper bag
  • Collect leaves, grass, sand, and other materials occasionally found in the hair or on the skin and retained as evidence.
  • Collect potential oral evidence using swabs rubbed between the teeth and the buccal mucosa on both upper and lower gingival surfaces bilaterally.
  • Collect fingernail scrapings when indicated by history:
    • Clean under the patient's fingernails with a toothpick or cut the nails closely over a clean paper
    • Fold the toothpick and debris into the paper, place in an envelope, and package with the other specimens
  • Collect dried liquid stains (potential saliva, semen, or other perpetrator body fluids) on the patient's skin by rolling swabs moistened with distilled or sterile water over the area until the swab has absorbed this material.
  • Swab areas of potential saliva or semen as dictated by patient history.
  • Comb or brush the patient's pubic hair:
    • Place a clean paper below the patient's buttocks
    • From the lithotomy position, comb the pubic hair inferiorly onto the paper
    • Fold hairs and comb or brush into the paper and place directly into a large paper envelope
  • Collect several swabs from the vaginal pool, external genitalia (including penis and scrotum in the male), and anus:
    • Collect vaginal washing if requested by local jurisdictions by inserting 5 mL of sterile (but not bacteriostatic) water or saline into the vagina, removing, and placing in a sealed container or test tube
    • Collect cervical swabs if the time from assault to examination (the postcoital interval) is greater than 48 hours or if there is a history of recent consensual (nonassault) intercourse
    • Collect anal swabs by inserting approximately 2 cm into the anus and gently moving in a circular motion
    • Make slides from wet swabs if dictated by local protocol
    • Perform immediate vaginal wet mount to identify motile spermatozoa if postcoital interval is less than 8 hours and examiner has sufficient experience and access to a microscope.
    • Dry, label, and package all swabs and slides
    • Meticulously label all materials and note collection time in the chart
  • Submit all specimens to law enforcement:
    • Label each sample with the patient's name, the hospital number, the date and time of collection, the area from which the specimen was collected, and the collector's name
    • Package specimens according to local crime lab specifications and transfer to the next appropriate official (police officer, pathologist, or other individual) along with a written “chain of evidence”
    • Include a list of the specimens, the signature of each person who provided them, and the signature of each person who received them to preserve the “chain of evidence”
  • See table Evidence Collection.
Background | Back to top


Collect samples to test for sexually transmitted diseases that are not completely treated after the assault. B

  • Only collect genital or urine samples for routine bacterial STD testing if prophylaxis is deferred.
  • Perform serologic testing for:
    • HIV
    • Hepatitis B
    • Syphilis, if prophylaxis directed against incubating syphilis is not given
  • See table Laboratory and Other Studies for Sexual Assault.
Background | Back to top


Collect blood, buccal, and urine specimens for crime lab testing for DNA reference, pregnancy, and toxicology analysis if indicated. B

  • If requested by the local crime lab, collect control samples for patient DNA reference such as blood, buccal mucosa cells, head hairs, or pubic hairs.
  • When collecting blood for toxicology testing, record the exact time on the specimen so the criminalist can estimate dose and timing of substances used to perpetrate the assault.
  • Obtain bedside urine β-HCG testing in all women patients of childbearing age.
  • See table Evidence Collection.
  • See table Laboratory and Other Studies for Sexual Assault.
Background | Back to top


FAQs
Carolyn J. Sachs, MD, MPH has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations.
Steven E. Weinberger, MD, FACP, Acting Editor, PIER, has stock holdings in Glaxosmithkline and Abbott.

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP. Because all PIER modules are updated regularly, printed web pages or PDFs may rapidly become obsolete. Therefore, PIER users should compare the date of the last update on the website with any printout to ensure that the information being referred to is the most current available.
PIER is copyrighted (c) 2009 by the American College of Physicians,
190 N. Independence Mall West, Philadelphia, PA 19106-1572, USA.