Recommendations at a Glance

C. The Examination Process

1. Initial contact: Some sexual assault patients may initially present at a designated exam facility, but most who receive immediate medical care initially contact a law enforcement or advocacy agency for help. If 911 is called, law enforcement or emergency medical services (EMS) may be the first to provide assistance to victims. Communities need to have procedures in place to promptly respond to disclosures/reports of sexual assault in a standardized and victim-centered manner.

Recommendations for jurisdictions and responders to facilitate initial contact with victims:

Build consensus among involved agencies regarding procedures for a coordinated initial response when a recent sexual assault is disclosed or reported. Educate responders to follow procedures
Recognize essential elements of initial response.

2. Triage and intake: Once patients arrive at the exam site, health care personnel must evaluate, stabilize, and treat for life-threatening and serious injuries according to facility policy. Standardized procedures for response in these cases should be followed, while respecting patients and maximizing evidence preservation.

Recommendations for health care providers to facilitate triage and intake that addresses patients’ needs:

Consider sexual assault patients a priority.
First perform a prompt, competent medical assessment. Then respond to acute injury, the need for trauma care, and safety needs of patients before collecting evidence.
Alert examiners of the need for their services.
Contact victim advocates so they can offer services to patients, if not already done.
Assess and respond to safety concerns upon arrival of patients at the exam site, such as threats to patients or staff.
Assess patients’ needs for immediate medical or mental health intervention prior to the evidentiary exam, following facility policy.

3. Documentation by health care personnel: Examiners document exam findings, the medical forensic history, and evidence collected in the medical forensic report.

Recommendations for health care providers to complete needed documentation:

Ensure completion of all appropriate documentation.
Educate examiners on proper documentation.
Ensure the accuracy and objectivity of medical forensic reports.

4. The medical forensic history: Examiners ask the patient questions in a language the patient understands to obtain this history. This information guides them in examining the patient and collecting evidence.

Recommendations for health care providers to facilitate gathering information from patients:

Coordinate medical forensic history taking and investigative interviewing.
Advocates should be able to provide support and advocacy during the history, if desired by patients.
Consider patients’ needs prior to and during information gathering.
Obtain the medical forensic history.

5. Photography: Photographic documentation of injury or other visible evidence on the patient’s body can supplement the medical forensic history and the written documentation of physical findings and evidence.

Recommendations for health care providers and other responders to photograph documentation:

Consider the extent of forensic photography necessary.
Consider the equipment.
Consider patient comfort and privacy.
Explain forensic photography procedures to patients.
Take initial and follow-up photographs as appropriate, according to jurisdictional policy.

6. Exam and evidence collection procedures: Examiners examine patients and collect evidence according to jurisdictional policy. Findings from the exam and collected evidence often help reconstruct the events in question in a scientific and objective manner.

Recommendations for health care providers to conduct the exam and facilitate evidence collection:

Recognize the evidentiary purpose of the exam.
Strive to collect as much evidence from patients as possible, guided by the scope of informed consent, the medical forensic history, exam findings, and instructions in the evidence collection kit.
Be aware of and document evidence and injuries that may be pertinent to the issue of whether the patient consented to the sexual contact with the suspect.
Understand how biological evidence is tested.
Prevent exposure to infectious materials and risk of contamination of evidence.
Understand the implications of the presence or absence of seminal evidence.
Modify the exam and evidence collection to address the specific needs and concerns of patients.
Explain exam and evidence collection procedures to patients.
Conduct the general physical and anogenital exam and document findings on body diagram forms.
Collect evidence to submit to the crime lab for analysis, according to jurisdictional policy.
Collect other evidence.
Keep medical specimens separate from evidentiary specimens collected during the exam.

7. Alcohol and drug-facilitated sexual assault: Responders must consider the possibility that drugs and/or alcohol may have been used to facilitate an assault. They must know how to screen for suspected alcohol and drug-facilitated sexual assault, obtain informed consent of patients for testing, and collect toxicology samples when appropriate.

Recommendations for jurisdictions and responders to facilitate response in suspected alcohol- or drug-facilitated sexual assault:

Promote training and develop jurisdictional policies.
Plan response to voluntary use of drugs and/or alcohol by patients.
Be clear about the circumstances in which toxicology testing may be indicated. Routine testing is not recommended.
Toxicology testing procedures should be explained to patients.
Toxicology samples should be collected as soon as possible after a suspected drug-facilitated case is identified and informed consent is obtained, even if patients are undecided about reporting to law enforcement.
Identify toxicology laboratories.
Preserve evidence and maintain the chain of custody.

8. Sexually transmitted infection (STI) evaluation and care: Because contracting an STI from an assailant is of significant concern to patients, it should be addressed during the exam.

Recommendations for health care providers to facilitate STI evaluation and care:

Offer patients information in a language they understand.
Consider the need for STI testing on an individual basis.
Encourage patients to accept prophylaxis against STIs if indicated.
Encourage follow-up STI exams, testing, immunizations, counseling, and treatment as directed.
Address concerns about HIV infection.

9. Pregnancy risk evaluation and care: Patients may fear becoming pregnant as a result of an assault. Health care providers must address this issue according to facility and jurisdictional policy.

Recommendations for health care providers to facilitate pregnancy evaluation and care:

Discuss the probability of pregnancy with patients who have reproductive capability.
Administer a pregnancy test for all patients with reproductive capability (with their consent).
Discuss treatment options with patients in their preferred language.

A victim of sexual assault should be offered prophylaxis for pregnancy, subject to informed consent and consistent with current treatment guidelines. Conscience statutes will continue to protect health care providers who have moral or religious objections to providing certain forms of contraception. In a case in which a provider refuses to offer certain forms of contraception for moral or religious reasons, victims of sexual assault must receive information on how to access these services in a timely fashion.

10. Discharge and follow-up: Health care personnel have specific tasks to accomplish before discharging patients, as do advocates and law enforcement representatives (if involved). Responders should coordinate discharge and follow-up activities as much as possible to reduce repetition and avoid overwhelming patients.

Recommendations to facilitate discharge and follow-up:

Address issues related to medical discharge and follow-up care.
Advocates, law enforcement representatives, and other involved responders can coordinate with health care providers to discuss a range of other issues with patients prior to discharge.

11. Examiner court appearances: Health care providers conducting the exam should expect to be called on to testify in court as fact and/or expert witnesses.

Recommendations for jurisdictions to maximize the usefulness of examiner testimony in court:

Encourage broad education for examiners on testifying in court.
Promote prompt notification of examiners if there is a need for them to testify in court.
Encourage pretrial preparation of examiners.
Encourage examiners to seek feedback on testimony to improve effectiveness of future court appearances.

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