Sexual assault

Sexual assault: overview 614

Sexual assault: history and examination 616

Sexual assault: management 618

614 CHAPTER 19 Sexual assault

Sexual assault: overview

Sexual offences and rape definitions vary from country to country.

Sexual Offences Act 2003 (UK)

•Rape: is defined as non-consensual penetration of mouth, vagina, or anus by a penis.

•Sexual assaults: are acts of sexual touching without consent. Sexual assault by penetration involves insertion of object or body parts other than penis into vagina or anus (previously indecent assault).

•Children under 13 cannot legally consent to sexual activity and therefore do not need proof of consent. Mistaken belief of age is not a valid defence.

In assessing a potential victim it is important to establish:

•Whether a sexual act has occurred.

•When it occurred.

•Ability of client to give consent to forensic examination: age, understanding, language, maturity, injury, or intoxication.

•Need for interpreters, ‘appropriate adult’, or advocate if under age of 16, or with learning difficulties.

•Need of assessment for any acute psychiatric or physical symptoms must always take precedence over forensic examination if needed.

•If reported to the police or victim wants to report it to the police.

1 It is crucial that advice is sought from the police or a Sexual Assault Referral Centre (SARC) before any examination is undertaken, to preserve possible evidence available.

Presentation

Acute on chronic is also common, particularly with children.

Acute

Victims of acute sexual assault may report to the police directly, or to A&E, GUM, gynaecological, or psychiatric services with covert or overt symptoms. It is crucial to any criminal case that evidence is gathered appropriately and the chain of evidence maintained. 16–58% have genital injuries, but a higher proportion (38–80%) have non-genital injuries. Many have no injuries at all.

1 Always consult with the police/SARC if there is any doubt about an individual’s presentation.

Delayed

Abuse can present with a number of symptoms (recent or historical). GUM gynaecology, and psychiatry are frequent specialties for disclosure of sexual assault or abuse. There is a significant increase in domestic violence and assault during pregnancy so antenatal services must include screening and referral facilities.

SEXUAL ASSAULT: OVERVIEW 615

Sexual assault: facts and figures

•The lifetime risk of sexual assault is 1 in 4–6 for women.

•It is estimated that only 1 in 5 adult rapes is reported.

•1 in 10 victims of sexual assault are men.

•12% of assaults are by strangers.

•45% are by acquaintances and 43% by intimate partners.

•45% involve vaginal rape, 10% anal rape, 15% oral rape, and 25% digital penetration.

•The incidence of child sexual abuse is unknown and possibly only 1 in 20–50 assaults of children are known to supervising authorities.

•The prevalence is far higher than that reflected in numbers reported.

Sexual abuse in children

Concern for children is heightened by:

•Repeated A&E attendances.

•Poor parent–child interactions or behaviour.

•Child known to social services.

•Any injuries to child under 1yr.

•History of domestic abuse.

•Explanation inconsistent with injuries.

•Disclosure of abuse by child.

•Delay in presentation.

1 Any concerns should be passed onto the local Safeguarding lead— this may be a nurse, midwife, or paediatrician in your local organization.

616 CHAPTER 19 Sexual assault

Sexual assault: history and examination

History

•Written consent: taken before any forensic medical examination. Children <13yrs need an adult with parental responsibility with them to provide written consent. Children 13–16 may consent if considered competent, but should be supported by a responsible adult—ideally one with parental responsibility.

•Confidentiality issues: victim may agree to only partial release of information and samples, but is able to change this decision later; forensic samples can be stored for up to 30yrs or 30yrs after their 18th birthday. The SARC would take and store such samples.

Examination

Examination can be performed by the SARC team at the same time as a gynaecological/general examination if necessary (e.g. in A&E or theatre), although it is usually done in the SARC suite. If the victim is <13yrs a paediatrician will normally be in attendance as well as a forensic medical examiner.

The time of the examination and sampling should be noted. The presence of pre-existing conditions such as skin problems or markers of selfharm must also be documented.

Key examination points

•Demeanour.

•Intoxication.

•Height/weight/BP/pulse/temperature.

•General findings.

•Injuries (record accurately with diagrams—photographs may be used (involvement of police photographer is preferred):

•non-genital: none, bruising, petechiae, abrasions, lacerations, incisions, defence injuries

•genital and anal: none, bruising, abrasions, lacerations, incisions, structure of hymen/remnants in those sexually active (or not)

•oral: mucosa, teeth, tongue.

•Clothes may also be important for evidence.

Collecting evidence

•Early evidence kits should be available in all A&E departments or can be brought by the police/forensic examiner. If at all possible evidence should be obtained by someone trained in this procedure, to ensure the highest quality evidence is obtained.

•Evidential samples for sexual offences are likely to be: semen, saliva, vaginal samples, urine, blood, faeces, hair, fibres, vegetation, sanitary pads and/or tampons, toilet paper, clothes, and condoms.

SEXUAL ASSAULT: HISTORY AND EXAMINATION 617

Key samples for reported sexual assault

•Oral intercourse: mouth swab/saliva/mouth wash +/– appropriate skin swab.

•Vaginal intercourse—swabs: vulval and perineal (both ×2), low vaginal (×2), high vaginal with a Cuscoe’s speculum (×2), endocervical (×2), from speculum (×1).

•Lubricant used is also sent.

•Anal intercourse—swabs: perianal (×2), rectal (×2), and anal (×2) with proctoscope.

•Buccal swabs are taken for victim DNA.

•Double swabs = 1 dry + 1 wet with saline as these have shown the best return of DNA.

•Fingernail (×2) and hand (×2) swabs and skin (×2 from each site) if stranger assailant.

•Timescales: mouth samples for DNA within 48h, skin samples collected within 48h, digital penetration within 12h, penile within 72h, anal within 72h, and vaginal up to 7 days postassault.

•Blood and urine for toxicology should be taken <72h and urine can be useful up to 14 days postassault.

2 Forensic examination at >7 days for women and >72h for men is unlikely to provide useful DNA evidence; however, it may still be appropriate for documentation of injuries.

618 CHAPTER 19 Sexual assault

Sexual assault: management

Emergency contraception

Should be given if there has been any vaginal contact in women or menstruating girls, irrespective of stage of menstrual cycle. Current recommendations: levonorgestrel 1500 micrograms start within 72h of sexual act (doubled if PEP is used) or IUCD insertion with antibiotic cover within 5 days. Ulipristal can now also be considered within 120h.

Sexually transmitted infections

Risk is estimated at 4–56% depending on the local prevalence and degree of trauma. Consider prophylactic antibiotics particularly if the victim is unlikely to attend for follow-up: 1g azithromycin + 500mg ciprofloxacin (or follow local guidelines). STD screening 2wks after the assault is recommended. Hep B vaccination should be discussed and given where indicated. PEP of HIV should always be considered and discussed (see Box 19.1).

Psychological care

Those at immediate risk of self-harm or suicide must be referred to oncall psychiatric services. Others may be referred to local counselling or support services as well as being given details of emergency out of hours contacts (see b Sexual assault: management, Further reading and useful websites, p. 619). Counselling should aim to contain the trauma of the experience and help the victim bear the ‘unbearable’. Those with persistent symptoms after 6mths may have posttraumatic stress disorder and need referral to psychiatric services. Be aware of local services and charities in your area that may provide support to victims of sexual assault and give the victim their details.

Child sexual abuse

It is difficult to know proportions of extra-familial and intra-familial sexual abuse because of underreporting (possibly 2/3 to 1/3, respectively, of reported abuse). Most children do not present acutely and may present because of Social Services or medical concerns regarding chronic physical illness, failure to thrive, or neglect.

1Emergency contraception must be remembered in pubescent girls. STIs diagnostic for child sexual abuse are:

•Gonorrhoea (if over 1yr).

•Syphilis and HIV (if congenital infection excluded).

• Chlamydia (if over 3yrs).

Any victim who has children or any young person <16yrs should be automatically referred to social services. All children <13yrs are followed up by the community paediatrician responsible for safeguarding in their area. Those >13yrs can be followed up in the SARC if appropriate.

SEXUAL ASSAULT: MANAGEMENT 619

Principles

•Resuscitation/usual ‘ABC’ measures are of overriding importance.

•Consideration of collection of evidence.

•Prophylactic antibiotics.

•Postexposure prophylaxis for HIV.

•Emergency contraception.

•Hepatitis B vaccination.

•Analgesia.

•General advice and support.

•Follow-up including counselling.

Risk of transmission of HIV with single exposure (higher if traumatic)

•Receptive vaginal intercourse: 1 in 600–2000.

•Receptive anal intercourse: 1 in 30–150.

Box 19.1 HIV and sexual assault

Risk is dependent on the prevalence in the population and trauma of assault. The prescribing of PEP must be carefully balanced against the side effects and risks of taking them. Consider the higher risk factors: assailant HIV positive or in risk group, anal rape, trauma and bleeding, multiple assailants. If in doubt seek advice from a local HIV physician.

•PEP: currently 3 antiretroviral drugs taken ASAP (within 1h if possible) and within 72h. Appropriate follow-up within the week must be arranged for a baseline HIV test, U&E, LFT, FBC because of the toxicity of these drugs. PEP is taken for 1mth and involves several follow-up visits. Full compliance is essential to prevent the emergence of resistant HIV strains. A follow-up HIV test after

6mths is recommended. Counselling is therefore essential prior to prescription of PEP.

•There are no studies of the efficacy of PEP after sexual exposure.

Further reading and useful websites

Brook: helpline and online enquiry service for the under-25s. Mwww.brook.org.uk. Tel: 020 7284 6040.

Rape Crisis Federation. Mwww.rapecrisis.org.uk (local numbers available from website). Rights of Women. Mwww.rightsofwomen.org.uk. Tel: 020 7251 6577.

Samaritans. Mwww.samaritans.org.uk. Tel : 08457 90 90 90.

Suzy Lamplugh Trust: for issues of personal safety. M www.suzylamplugh.org.uk. Tel: 020 8392 1839

The Havens: London Sexual Assault Referral Centres. Mwww.thehavens.co.uk.

Victim Support: for victims of all crimes including sexual assault. M www.victimsupport.org.uk . Tel: 0845 30 30 900.

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