Sexual Assualt Examination 61 Chapter 3 Sexual Assault Examination Deborah Rogers and Mary Newton 1. INTRODUCTION Sexual assaults create significant health and legislative problems for every society. All health professionals who have the potential to encounter victims of sexual assaults should have some understanding of the acute and chronic health problems that may ensue from an assault. However, the pri- mary clinical forensic assessment of complainants and suspects of sexual assault should only be conducted by doctors and nurses who have acquired specialist knowledge, skills, and attitudes during theoretical and practical training. There are many types of sexual assault, only some of which involve pen- etration of a body cavity. This chapter encourages the practitioner to under- take an evidence-based forensic medical examination and to consider the nature of the allegation, persistence data, and any available intelligence. The chapter commences by addressing the basic principles of the medical examination for both complainants and suspects of sexual assault. Although the first concern of the forensic practitioner is always the medical care of the patient, thereafter the retrieval and preservation of forensic evidence is para- mount because this material may be critical for the elimination of a suspect, identification of the assailant, and the prosecution of the case. Thus, it is imper- ative that all forensic practitioners understand the basic principles of the foren- sic analysis. Thereafter, the text is divided into sections covering the relevant body areas and fluids. Each body cavity section commences with information regard- From: Clinical Forensic Medicine: A Physician’s Guide, 2nd Edition Edited by: M. M. Stark © Humana Press Inc., Totowa, NJ 61 62 Rogers and Newton ing the range and frequency of normal sexual practices and the relevant anatomy, development, and physiology. This specialist knowledge is manda- tory for the reliable documentation and interpretation of any medical findings. The practical aspects—which samples to obtain, how to obtain them, and the clinical details required by the forensic scientist—are then addressed, because this takes priority over the clinical forensic assessment. The medical findings in cases of sexual assault should always be addressed in the context of the injuries and other medical problems associated with con- sensual sexual practices. Therefore, each section summarizes the information that is available in the literature regarding the noninfectious medical compli- cations of consensual sexual practices and possible nonsexual explanations for the findings. The type, site, and frequency of the injuries described in asso- ciation with sexual assaults that relate to each body area are then discussed. Unfortunately, space does not allow for a critical appraisal of all the chronic medical findings purported to be associated with child sexual abuse, and the reader should refer to more substantive texts and review papers for this infor- mation (1–3). Throughout all the stages of the clinical forensic assessment, the forensic practitioner must avoid partisanship while remaining sensitive to the immense psychological and physical trauma that a complainant may have incurred. Although presented at the end of the chapter, the continuing care of the com- plainant is essentially an ongoing process throughout and beyond the primary clinical forensic assessment. 2. BASIC PRINCIPLES OF THE MEDICAL EXAMINATION 2.1. Immediate Care The first health care professional to encounter the patient must give urgent attention to any immediate medical needs that are apparent, e.g., substance overdose, head injury, or serious wounds. This care takes precedence over any forensic concerns. Nonetheless, it may be possible to have a health care worker retain any clothing or sanitary wear that is removed from a complainant until this can be handed to someone with specialist knowledge of forensic packag- ing. 2.2. Timing of the Examination Although in general terms the clinical forensic assessment should occur as soon as possible, reference to the persistence data given under the relevant sections will help the forensic practitioner determine whether the examination of a complainant should be conducted during out-of-office hours or deferred Sexual Assualt Examination 63 until the next day. Even when the nature of the assault suggests there is unlikely to be any forensic evidence, the timing of the examination should be influenced by the speed with which clinical signs, such as reddening, will fade. 2.3. Place of the Examination Specially designed facilities used exclusively for the examination of com- plainants of sexual offenses are available in many countries. The complainant may wish to have a friend or relative present for all or part of the examination, and this wish should be accommodated. Suspects are usually examined in the medical room of the police station and may wish to have a legal representative present. During the examinations of both complainants and suspects, the local ethical guidance regarding the conduct of intimate examinations should be followed (4). 2.4. Consent Informed consent must be sought for each stage of the clinical forensic assessment, including the use of any specialist techniques or equipment (e.g., colposcope) and obtaining the relevant forensic samples. When obtaining this consent, the patient and/or parent should be advised that the practitioner is unable to guarantee confidentiality of the material gleaned during the medical examination because a judge or other presiding court officer can rule that the practitioner should breach medical confidentiality. If photo documentation is to form part of the medical examination, the patient should be advised in ad- vance of the means of storage and its potential uses (see Subheading 2.8.); specific written consent should then be sought for this procedure. The patient must be advised that he or she can stop the examination at any time. 2.5. Details of the Allegation If the complainant has already provided the details of the allegation to another professional, for example, a police officer, it is not necessary for him or her to repeat the details to the forensic practitioner. Indeed, Hicks (5) notes that attempts to obtain too detailed a history of the incident from the complainant may jeopardize the case at trial because at the time of the medical examination the patient may be disturbed and, consequently, the details of the incident may be confused and conflict subsequent statements. The details of the allegation can be provided to the forensic practitioner by the third party and then clarified, if necessary, with the complainant. It may be difficult for the complainant to describe oral and anal penetrative sexual assaults, and the forensic practitioner may need to ask direct questions regarding these acts sensitively (6). 64 Rogers and Newton 2.6. Medical and Sexual History The purpose of obtaining the medical and sexual history is essentially twofold: first, to identify any behavior or medical conditions that may cause the doctor to misinterpret the clinical findings, for example, menstrual bleed- ing; and second, to identify any medical problems that may be attributable to the sexual assault, for example, bleeding, pain, or discharge. Other specific details may be required if emergency contraception is being considered. When children are examined, the parent or caregiver should provide comprehensive details of the past medical history. When adults are exam- ined, only relevant medical and sexual history should be sought because confidentiality cannot be guaranteed. What constitutes relevant medical his- tory must be determined on a case-by-case basis by considering the differ- ential causes for any medical findings and the persistence data for the different sexual acts. Forensic practitioners should not ask suspects about the alleged incident or their sexual history. 2.7. Nature of the Examination 2.7.1. General Examination In all cases, a complete general medical examination should be conducted to document injuries and to note any disease that may affect the interpretation of the medical findings. 2.7.2. Anogenital Examination Whenever there is a clear account of the alleged incident, the anogenital examination should be tailored to the individual case (e.g., if an adult com- plainant only describes being made to perform fellatio, there is usually no indication to examine the external genitalia). However, in some cases, the complainant may not be aware of the nature of the sexual assault. Further- more, children and some adults may not have the language skills or may feel unable to provide a detailed account of the sexual acts at the initial interview. In such cases, a comprehensive anogenital examination should be undertaken if the patient or the person with legal authority to consent on behalf of the patient gives his or her consent. 2.8. Ownership and Handling of Photo Documentation Any video or photographic material should be retained as part of the practitioner’s confidential medical notes and stored in a locked cabinet a locked premises. To preserve anonymity, the material should be labeled both on the Sexual Assualt Examination 65 casing and within the video/photograph itself (by holding a card within the frame) using either a unique identification code or the patient’s initials and the date of the examination. With the specific consent of the patient, the video/ photograph can be shown to other colleagues for second