Management of sexual assault in the ED

1. August 2015
Dr Sarah Jolly
Joanne Willox

2.  Questionnaire
 A Case Study
 Definitions
 Legislation
 History & Examination
 Early Evidence Kits
 SARC services

3.  I 3 point ID completed verbally with pt.
 S 38yo ♀ referred to SW by Medical for
psychosocial and safety assessment post
sexual assault.
 O Pt was observed to be scared, frightened,
withdrawn and very teary.
 B Numerous grief/loss issues (parents
deceased, estranged from sibs, not caring for
children), hx of IVDU and physical assaults

4.  A Attempt to contact NOK at pt request (distinction
between being alone and lonely).
On-going liaison with WAPOL re forensic specimens:
ROG, Response Team, SA Squad
On-going liaison with SARC.
Access to refuge accommodation (8 calls)
Consultation with CPFS re care status of child.
 R Comprehensive Discharge Plan including
Safety Plan, accommodation, clothing, transport,
counselling and crisis payment info.

6.  Fortunately we do not see a lot
 SARC see >300 emergency cases per year

7.  Broad definition
Any sexual activity carried out against the will of a
person through the use of violence, coercion or
intimidation, even if it did not end in penetration.

8.  Any unwanted sexual touch
 Being forced to masturbate or watch someone
else masturbate
 Being forced to give/receive oral sex
 Being forced to perform sexual acts on oneself
or others
 Sexual penetration by penis/object/other parts
of the body into vagina/anus/mouth

9.  WA Criminal Code
-Sexual penetration without consent
-Aggravated sexual penetration without consent
Aggravated can include: causing injury; using a weapon; detaining the
complainant; the complainant’s age; if the complainant has a disability
-Indecent assault
-Aggravated indecent assault
Consent = freely given & voluntarily given
without force/threat

10.  16 years in WA
 18 for anal sex in Queensland
 Some nations only 15 years
 PNG – 16 yrs for girls and 14 yrs for boys
 People of authority

11.  Is a free agreement – which cannot be given if
intoxicated, frightened, asleep, unconscious,
forced or coerced, no capacity to understand
what is happening, too young
 Consent can be withdrawn at any time

12.  If belief that a child/young person (<18yrs) has
been subject of sexual abuse
Freephone: 1800 708 704
www.mandatoryreporting.dcp.wa.gov.au

13.  Lifetime prevalence of sexual abuse/assault?

15. Sexual Assault & Abuse
Mental Health
Issues
Alcohol & Drug
Issues

16. Has an impact on-
 The likelihood of the person seeking further
assistance
 The likelihood of the person/complainant
reporting the crime and proceeding through
the criminal justice system

17.  Listen & Believe
 Private space
 Reassure & be empathic
 Uncomfortable for both pt & staff

18.  Open
Direct disclosure of sexual assault
Brought to ED by police
 Indirect presentation
Injury/Domestic violence
Requiring emergency contraception/STI screen
Intoxication +/- memory loss
Mental health w self-harm/suicidal ideation

19. Psychosocial issues
Medical issues
Forensic issues
Mandatory reporting
Consult SARC early

20.  Is patient safe?
From perpetrator
From themselves
Other mental health problems
 Are children safe?
 Does pt have somewhere safe to go?
 Psych/Social worker referral
 Pt can call/be seen by SARC for counselling

21.  Injuries
-Acute medical takes priority over forensic
-5% have moderate & 1% severe physical injury
(head injuries, strangulation, fractures,
widespread soft tissue injuries)
-likelihood of significant genital injury is
uncommon (except in pre-pubertal girls & post-
menopausal women)

22.  Contraception
-Risk of pregnancy?
-Emergency contraception
-Give ASAP up to 72 hours (or ?longer, may be
have some effect up to 5 days)

23.  STI screening
-First void urine
-Serology – Hep B, C, HIV, syphilis
-Genital/oral/anal swabs if appropriate, but
consider need for forensic examination/specimen
collection

24.  Azithromycin 1g orally for chlamydia alone
 ?Gonorrhoea - depends on region, risk &
likelihood of compliance
Ceftriaxone 500mg in 2mls 1% lignocaine IM
AND
Azithromycin 1g orally
 Hep B vaccine/Ig if at risk
 HIV PEP is rarely required

25. HIV
 1/1250 risk from penile/vaginal & 1/60 from
penile-anal with a known HIV positive male
 Risk increases w genital injury, concurrent STI,
receptive anal assault, assailant factors (high
prevalence countries, IVDU & MSM)

26.  2 anti-retrovirals for 1 month
 Side effects rare
GI upset, headaches, rash, renal/liver dysfunction
 D/W Immunology Reg on-call

27.  Sexual health clinic
 1 month: repeat swabs & urine, pregnancy test
 3 months: repeat serology
 Hep B vaccinations at both if required

28.  A forensic medical examination can only be
conducted with a patient’s fully informed
consent
 It is not done for therapeutic reasons, but to
assist a criminal investigation
 Informed consent
-is specific
-freely given, no coercion
-competently given
-pt needs capacity

29.  May consent to one part, but not another
 Right to withdraw consent
 <18 yrs – need child’s assent AND responsible
person’s consent
 <18 yrs – can consent to medical, but not
forensic component depending on if police are
involved
 Intoxicated – must wait until sober, but
consider EEKs

30.  Not required in our ED
 Unlikely to ever need to do it
 Very detailed
 Takes a long time

31.  Brief history of assault and any injuries
 Date, time and duration of the forensic
examination
 Document source of information – police,
patient/victim
 Direct quotes are helpful - patient’s own words
 Volunteered v direct questioning
 When, where and who of the alleged incident
 Number assailants
 Relationship to assailant

32.  Force or weapon, threats
 Penetration or attempted penetration
 Patient actions in defence eg. scratching
 Possible ejaculation and where on body/clothing
 Condom use, lubrication, saliva
 Any discomfort, dysuria, genital or anal bleeding
 What has happened since the alleged assault eg
showering, changing clothes
 Anything else?

33.  As you would for any other patient
 Injury
Do you have any injuries that are not obvious to me? Head
injury, loss of consciousness, strangulation, genito-anal injury.
 Gynaecological history
Last menstrual period, pregnancy, contraception, sexual
partners within last 10 days, pre-existing discharge or concern,
previous sexual abuse/assault
 Mental health
Have you suffered from stress or depression in the past? Have
you ever thought of hurting yourself? Do you feel safe from
yourself? Are you safe from others? Who would you go to for
support in difficult times?

34.  Site
 Position (distance from anatomical landmarks)
 Injury type
 Colour (shape, surface, margins, healing)
 Size /Dimensions
 Associated swelling/debris/infection

35.  Bruise
 Abrasion
 Laceration
 Incised wound
 Mixed

36.  Redness – could be from infection,
inflammation or trauma
 Tenderness - subjective

37.  Leakage of blood from blood vessels in the skin
and subcutaneous tissues, which have been
disrupted by blunt force
 You cannot age a bruise

38.  Petechial – often arises from disruption of
small venules, eg. above site of strangulation,
suction type injury
 Tramline – struck with a rod-like object
 Fingerpad
 Patterned

39.  The presence of yellow discolouration in a
bruise indicates it is older than 18 hours
 Very subjective

40.  Result from simultaneous application of force
and movement to the skin causing disruption
of its outer layers
-linear
-brush
 Can be a directional component with skin tags
at the end of the abrasion
 Describe any bleeding, scabbing or dehiscence
of scabs, but it is not possible to give an a clear
indication of its age

41.  Result from the application of a blunt force
which causes splitting or tearing of the skin
and/or subcutaneous tissues
 Different to an incised wound which is caused
by a sharp force

42.  Incised wounds – length greater than depth
 Stab wounds – depth greater than length,
underlying structures damaged
 Other
- burns (heat, eg cigarette & chemical)
- gunshot

43.  Not practical in the ED
 NO personal mobile phones
 Police photographers
 Chain of evidence

44.  Associating injury w possible
causes/mechanism
 Rare in medicine for a finding to have only one
possible mechanism of causation
 Risk of over-interpreting
 Need to be objective
 Respect boundaries of expertise
 Exact mechanism often not able to be
determined by physician

45.  May still be worthwhile even if
-the patient has showered/bathed/been for a
swim
-the person has had consensual sex w another
person before/after the assault
-the complainant doesn’t think the assailant
ejaculated
Samples can be collected & stored for up to 3/12

46. Oral DNA- 6 hours usually
up to 24 hours possibly
Affected by oral intake
Vaginal DNA- up to 24 hours usually
up to 3 days is likely
5-10 days is possible
Anal DNA- up to 24 hours
up to 48 hours possibly
Affected by bowel actions
Skin DNA- only 46 cells to identity DNA
up to first shower

47.  Formerly known as Preliminary Forensic Kits

48. Allows patient comfort with preservation of
evidence, prior to a formal forensic examination
It patient unsure if they want to report to
police/undergo formal exam
 Urine (biology & toxicology)
 Labial/Penile wipe +/- peri-anal wipe
 Oral rinse
 Blood (Toxicology)
 Clothing

49.  Blood
 Urine
Assists if victim was unable to consent to sexual
contact due to intoxication
 Document patient weight and collection time
 May have to collect before pt able to consent,
but await capacity before handing over to
police

50.  Available in the ED
 Standard hospital supplies can be used
 Plain labels (NOT hospital pt labels)
 Consent
 No need for these to be observed

51.  10mls sterile water
 1 yellow top container-labelled as “oral rinse”
 1 pair of gloves

52.  Pt to wear gloves & hold pot
 Place sterile water in mouth & thoroughly rinse
around
 Spit fluid into pot and replace top
 Label with pt name & date of birth

53.  2 yellow pots
 Labelled “urine” & “vulval wipe” or “penile
wipe”
 Sterile gauze
 10mls sterile water for men
 Pair of gloves
 Bright yellow sticker (Please fwd to C.C.WA)

54.  Pt given items & go to bathroom
 Pt puts on gloves
 First part urine into pot & replace top
 Use gauze to gently wipe vulva
 Men – moisten gauze w sterile water & wipe
shaft & tip of penis
 Place in pot, allow to dry before replacing lid
 Attach yellow label to urine sample

55.  If required
 Same procedure
 Gloves, moisten gauze with 10mls sterile water
& wipe around anus
 Place in pot, allow to dry

56.  Following suspected drug facilitated assault
 2 x fluoro-oxalate (grey) or 2 x EDTA (purple)
blood tubes
 Sterile water to clean skin
 Plain labels, Exact time of collection
 Toxicology consent form

57.  If pt wishes to change
 Separate PAPER bag for each item of clothing,
change gloves between items
 Seal & Label each bag

58.  Place all specimens, copy of consent & list of
specimens in envelope/plastic bag
 Seal w Evidence Label/completed label & sign
across it with your name, date & time
 Hand either to police OR to patient to take to
SARC (keep in fridge if going home first)
 Document in notes

59.  Always phone SARC for advice

60.  Document times and events
 Note who, what is done, when & where
 Seal all specimens in forensic envelopes with
red evidence tape to ensure that it is tamper
proof

61.  Swabs, slides, tape, envelopes etc in the Full
SARC sexual assault examination kits
 Probably only required in regional EDs/rural
clinics
 Here – go to SARC

62.  Awareness of risks
 Clean environment
 Use of bleach/trigone to clean surfaces pre &
post examination
 The Vincent Enquiry

63.  24-Hour Emergency Line
(08) 9340 1828
Freecall 1800 199 888
Business line (08) 9340 1820

64.  SARC
 N.E.I.Langlois and G.A.Gresham, “The Ageing of Bruises”: A
review and study of the colour changes with time,” Forensic
Science International, 50 (1991) pp227-238
 Maguire S, Mann MK, Sibert J, Kemp A (2005), 'Can you age
bruises accurately in children? A systematic review', Arch Dis
Child 90:187-189
 http://what-when-how.com/forensic-sciences/sexual-assault-
and-semen-persistence/
 http://aifs.gov.au
 http://www.mandatoryreporting.dcp.wa.gov.au

65.  Any questions?