The Examination Process

1. Initial contact
2. Triage and intake
3. Documentation by health care personnel
4. The medical forensic history
5. Photography
6. Exam and evidence collection procedures
7. Drug-facilitated sexual assault
8. Sexually transmitted infection (STI) evaluation and care
9. Pregnancy risk and evaluation care
10. Discharge and followup
11. Examiner court appearances

• Build consensus among involved agencies regarding procedures for a coordinated initial response when a recent sexual assault is disclosed or reported, and educate responders on procedures. Encourage victims to interact with advocates as soon after disclosure as possible. 
• Recognize essential elements of initial response. In particular, encourage victims to seek medical care and have evidence collected. In the case of life-threatening or serious injuries, obtain emergency medical assistance according to jurisdictional policy. Any life-threatening wounds should be treated and victims’ immediate safety needs should be addressed before evidence is collected. 
• If victims decide to seek medical care and/or have evidence collected, follow jurisdictional policies for preserving evidence, collecting a urine sample if needed, and transporting victims to the exam site. 

• Consider sexual assault patients a priority. Use private locations in the exam facility for the primary patient consultation and initial law enforcement interviews, offer a waiting area for family members and friends, and provide childcare if possible. 
• Respond to acute injury, trauma care, and safety needs of patients before collecting evidence. Patients should not wash, change clothes, urinate, defecate, smoke, drink, or eat until initially evaluated by examiners, unless necessary for treating acute medical needs.
• Alert examiners to the need for their services at the exam site. 
• Contact victim advocates so they can offer services to the patient, if not already done. 
• Assess and respond to safety concerns, such as threats to the patient or staff, upon arrival of patients at the exam site. 
• Assess patients’ needs for immediate medical or mental health intervention. Seek informed consent from patients before providing treatment, according to facility policy. 

• Ensure completion of all appropriate documentation. The forensic details of the exam are documented in the medical forensic report, according to jurisdictional policy. The only medical issues documented in this report are acute findings that potentially relate to the assault or preexisting medical factors that could influence interpretation of findings. Separate medical documentation by examiners and other involved clinicians follows a standard approach—address acute complaints, gather pertinent historical data, describe findings, and document treatment and followup care. 
• Ensure the accuracy and objectivity of medical forensic reports by seeking education on proper report writing. 

• Examiners should coordinate with other responders, primarily law enforcement representatives, to facilitate information gathering that is respectful to patients and minimizes repetition of questions.
• Keep in mind that advocates may support and advocate for patients when the medical forensic history is taken (if desired by patients), but they may not actively participate in the process. Patients should be informed that the presence of family members, friends, and others offering personal support during this time may influence or be perceived as influencing their statements. If patients choose to have others present despite this knowledge, these individuals should not actively participate in the process. 
• Consider and address patients’ needs prior to information gathering, including identifying the level of their communication skill and modalities and then tailoring information gathering accordingly. 
• Obtain the medical forensic history in a private, quiet setting.
• Gather information for the history according to jurisdictional policy. Include the date and time of the assault, pertinent patient medical history (e.g., menstruation history), recent consensual sexual activity of the patient, the patient’s activities since the assault (e.g., took a shower), the patient’s assault-related history (e.g., loss of consciousness), suspect information, if known (e.g., number and gender of assailants), nature of the physical assault, and description of the sexual assault. 

• Come to a consensus about the extent of forensic photography necessary. Some jurisdictions routinely take photographs of both detected injuries on patients and normal (apparently uninjured) anatomy, while others limit photography to detected injuries. 
• Consider who will take photographs and what equipment will be used. Photographers should be familiar with equipment operation as well as educated in forensic photography and in ways to maintain the patient’s privacy and dignity while taking photographs. Consult with jurisdictional criminal justice agencies and examiners regarding the type of equipment that should be used. 
• Obtain informed consent from patients before taking photographs. Patients should understand the purpose of the photographs, what will be photographed and any related procedures, the potential uses of photographs during investigation and prosecution, and the possible need for followup photographs. 
• Consider the patient’s comfort and need for modesty.  
• Identify who will be present when photographs are taken. 
• Take initial and followup photographs as appropriate, according to jurisdictional policy. 

• Strive to collect as much evidence from patients as possible, considering the scope of informed consent, the medical forensic history, the examination, and evidence collection kit instructions. 
• Be aware of evidence that may be pertinent to the issue of whether the patient consented to sexual contact with the suspect. Understand how biological evidence is tested. 
• Prevent exposure (of both patients and staff) to infectious materials and contamination of evidence. 
• Understand the implication of the presence or lack of semen (in cases involving male suspects). 
• Seek informed consent from patients for each portion of the exam and evidence collection. 
• Modify the exam and evidence collection to address the specific needs and concerns of patients. 
• Conduct the general physical and anogenital examination, guided by the scope of informed consent and the medical forensic history. Document findings on body diagram forms. With the patient’s consent, use an alternate light source, colposcope, and anoscope, as appropriate and if available, to increase the likelihood of detecting evidence. 
• Collect evidence to submit to the crime lab for analysis, according to jurisdictional policy. 
• Collect blood and/or urine for toxicology screening, if applicable. 
• Keep medical specimens separate from forensic specimens collected during the exam. 

• Educate examiners, 911 dispatchers, law enforcement representatives, prosecutors, judges, and advocates on related issues. Develop jurisdictional policies to clarify first responders’ roles in cases involving suspected drug-facilitated assault. 
• Be clear about the circumstances in which toxicology testing may be indicated (for optimal care or when there is a suspicion of drug-facilitated sexual assault). Routine toxicology testing in all sexual assault cases is not recommended.  
• Informed consent of patients should be sought to collect toxicology samples. Patients should be aware of the purposes and scope of testing that will be done, potential benefits and consequences of testing, any followup treatment necessary, how they can obtain results, who will pay for the testing, and if they have any opportunity to revoke consent to testing. 
• With patients’ permission, immediately collect a urine specimen if it is suspected that ingestion of drugs used to facilitate sexual assault occurred within 96 hours prior to the exam. The first available urine should be collected—law enforcement and emergency medical services should be trained and prepared to collect a urine sample if patients must urinate prior to arrival at the health care facility for the exam. Advocates and other professionals who may have contact with patients prior to their arrival at the exam site should also be educated to provide those who suspect drug-facilitated assault with information on how to collect a sample if the patient cannot wait to urinate until getting to the site.  
• Also, collect a blood sample if it is suspected that the ingestion of drugs used to facilitate sexual assault occurred within 24 hours of the exam. If a blood alcohol determination is needed, collect blood within 24 hours of ingestion of alcohol, according to jurisdictional policy. 
• Jurisdictional policies should be in place and followed for packaging, storing, and transferring samples. 

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. 

• Offer patients information about the risks of STIs (including HIV), the symptoms and what to do if symptoms occur, testing and treatment options, followup care, and referrals. Referrals should include free and low-cost testing, counseling, and treatment available in various sections of the community. For HIV testing, confidential and anonymous testing is recommended. 
• Consider testing patients for STIs during the initial exam on a case-by-case basis. If testing is done, follow the guidelines of the Centers for Disease Control and Prevention (CDC).  
• Encourage patients to accept prophylaxis against STIs during the initial exam. (Note, however, that treatment may not be appropriate for some individuals—for example, if they have a condition that may be adversely affected by taking prophylaxis.) The CDC suggests a regimen to protect against chlamydia, gonorrhea, trichomonas, and bacterial vaginosis (BV), as well as the hepatitis B virus. If accepted, provide care that meets or exceeds CDC guidelines. If declined, it is medically prudent to obtain cultures and arrange for a followup exam and testing. Seek informed consent from patients for treatment, according to facility policy. 
• Encourage and facilitate followup STI examinations, testing, immunizations, and treatment as directed. 
• Offer postexposure prophylaxis for HIV to patients at high risk for exposure, particularly when it is known that suspects have HIV/AIDS. Meet or exceed CDC recommendations. Discuss risks and benefits of the prophylaxis with patients prior to their decisions to accept or decline treatment. Careful monitoring and followup by a health care provider or agency experienced in HIV issues is required. 

• Discuss the probability of pregnancy with patients. 
• Administer a baseline pregnancy test for all patients with reproductive capability. 
• Discuss treatment options with patients, including reproductive health services. 

• It is important to ensure that patients are fully informed about postexam care. Information may include referrals to other professionals to make sure that patients’ medical and/or mental health needs related to the assault have been addressed, discharge instructions, followup appointments with the examiner or other health care providers, and contact procedures for medical followup. In addition to medical followup, followup may be indicated to document developing or healing injuries and complete resolution of healing. 
• Advocates and law enforcement representatives, if involved, should coordinate with examiners to discuss other issues with patients, including planning for their safety and well-being, physical comfort needs, information needs, the investigative process, advocacy and counseling options, and law enforcement and advocacy followup contact procedures. 

• 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.