Obtaining the history

Obtain the medical forensic history.  The specific questions asked of patients by examiners for the medical forensic history vary from one jurisdiction to the next, as do forms used to record the history.[1] The following information should be sought routinely from patients:[2] 
  1. Date and time of the sexual assault(s):  It is essential to know the period of time that has elapsed between the assault and the collection of evidence. Evidence collection may be directed by the time interval since the assault. Interpretation of both the physical exam and evidence analysis may be influenced by the time interval between the assault and the exam.
  2. Pertinent patient medical history:  The interpretation of physical findings may be affected by medical data related to menstruation, recent anal-genital injuries, surgeries, or diagnostic procedures, blood-clotting history, and other pertinent medical conditions or treatment.
  3. Recent consensual sexual activity:  The sensitivity of DNA analysis makes it important to gather information about recent consensual intercourse, whether it was anal, vaginal, and/or oral, and whether a condom was used. A trace amount of semen or other bodily fluid may be identified that is not associated with the crime. Once identified, it may need to be associated with a consensual partner, and then used for elimination purposes to aid in interpreting evidence.[3]
  4. Postassault activities of patients:  The quality of evidence is affected both by actions taken by patients and the passage of time. It is critical to know what, if any, activities were performed prior to the examination (e.g., have patients urinated, defecated, wiped genitals or the body, douched, removed/inserted a tampon/sanitary pad/diaphragm, used oral rinse/gargled, washed, brushed teeth, ate or drank, smoked, used drugs, or changed clothing?). 
  5. Assault-related patient history:  Information such as whether there was memory loss, lapse of consciousness, vomiting, nongenital injury, pain and/or bleeding, and anal-genital injury, pain, and/or bleeding can direct evidence collection and medical care. Collecting toxicology samples is recommended if there was either loss of memory or lapse of consciousness, according to jurisdictional policy. 
  6. Suspect information (if known):  Forensic scientists seek evidence on cross-transfer of evidence among patients, suspects, and crime scenes. The gender and number of suspects may offer guidance to types and amounts of foreign materials that might be found on patients’ bodies and clothing. Suspect information gathered during this history should be limited to that which will guide the exam and forensic evidence collection. Detailed questions about suspects are asked during the investigative interview. 
  7. Nature of the physical assault(s):  Information about the physical surroundings of the assault(s) (e.g., indoors, outdoors, car, alley, room, rug, dirt, mud, or grass) and methods employed by suspects is crucial to the detection, collection, and analysis of physical evidence. Methods may include, but are not limited to, use of weapons (threatened and/or injuries inflicted), physical blows, grabbing, holding, pinching, biting, using physical restraints, strangulation, burns (thermal and/or chemical), threat(s) of harm, and involuntary ingestion of alcohol/drugs. Knowing whether suspects may have been injured during the assault may be useful when recovering evidence from patients (e.g., blood) or from suspects (e.g., bruising, fingernail marks, or bite marks).
  8. Description of the sexual assault(s):  An accurate but brief description is crucial to detecting, collecting, and analyzing physical evidence.  The description should include any:[4] 
    • Penetration of genitalia (e.g., vulva, hymen, and/or vagina of female patient), however slight;[5] 
    • Penetration of the anal opening, however slight;
    • Oral contact with genitals (of patients by suspects or of suspects by patients);
    • Other contact with genitals (of patients by suspects or of suspects by patients);
    • Oral contact with the anus (of patients by suspects or of suspects by patients);
    • Nongenital act(s) (e.g., licking, kissing, suction injury, and biting);
    • Other act(s) including use of objects;
    • If known, whether ejaculation occurred and location(s) of ejaculation (e.g., mouth, vagina, genitals, anus/rectum, body surface, on clothing, on bedding, or other); and 
    • Use of contraception or lubricants.[6] 
These questions require specific and sometimes detailed answers. Some may be difficult for patients to answer. Examiners should explain that these questions are asked during every sexual assault medical forensic exam. They should also explain why each question is being asked. 

[1] In some jurisdictions, examiners ask for investigative details during history taking. In others, examiners only ask for information related to treatment and collecting/interpreting physical and lab findings. One concern is that investigative details reported by examiners that differ from the law enforcement report may be used against patients. (Drawn from L. Ledray, SANE Development and Operation Guide, 1998, p. 77.) Another concern is that asking investigative questions is outside the examiner’s role.
[2] Drawn from California’s Medical Forensic Report: Adult/Adolescent Sexual Assault Examination, Less Than 72 Hours (OCJP 923), the Tulsa Sexual Assault Report Form, and the West Virginia Protocol for Responding to Victims of Sexual Assault, 2002, pp. 40–42.
[3] Patients should be aware that there might be a need at a later time to obtain an elimination sample from consensual partners. Jurisdictions may have policies in place for seeking such samples within a certain timeframe following the exam. 
[4] Specific questions asked will depend on case facts (e.g., the gender of the patient and the gender of the suspect).
[5] Questions related to whether there was penetration should include what was used for penetration (e.g., penis, finger, or other object). 
[6] Certain contraceptive preparations can interfere with accurate interpretation of preliminary chemical tests frequently used in the analysis of potential seminal stains. In addition, contraceptive foams, creams, or sponges can destroy sperm. Lubricants of any kind are trace evidence and may be compared with potential sources left at the crime scene or recovered from bodies of suspects. Knowing whether or not a condom was used also may be useful in explaining the absence of semen.


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