Dr Hovelson is Clinical Instructor, Department of Obstetrics & Gynecology, University of Michigan Health System.

Sonia A Hovelson, MD

	By Sonia Hovelson, MD, Lisa Scheiman, CNM, and Mark Pearlman, MD

	

	None of the authors has a conflict of interest to report in respect to the content of this article.

A 17-year-old G0 presents to your clinic for an urgent visit requesting testing for sexually transmitted infections (STIs). She tells you that she is doing well with the birth control pills that she started after her last visit with you for contraception and reports a change in vaginal discharge but denies pelvic pain or other focal symptoms. Given the complaint about vaginal discharge, you perform a pelvic examination and find that the patient is exquisitely sensitive to even light touch of her external genitalia despite an entirely normal appearance.

Abandoning the pelvic examination, you help the patient sit up on the exam table and ask, “Have you ever had any trauma to that area of your body or any unwanted sexual contact?” The patient immediately bursts into tears and tells you that she was at a party at a friend’s house last night. After several alcoholic drinks, she reports, a male acquaintance took her upstairs to a bedroom and verbally pressured her into having sexual intercourse with him.

What do you do? Do you continue with the examination to ensure no injuries, despite her pain, or do you just talk about what happened without examination? Do you probe with detailed questions about the sequence of events of the assault, or do you allow the patient to tell the story at her own pace? Do you report this to the police, or do you leave reporting up to the patient?

	One of every 3 women experiences sexual violence in her lifetime.

 Sexual violence encompasses a wide range of acts, including prostitution, human trafficking, stalking, intimate partner violence, and sexual assault. Historically, there have been many different ways to define rape. The Federal Bureau of Investigation (FBI) defines rape as “penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim.”

 Sexual assault encompasses rape and also unwanted contact, including fondling, kissing, and sexual touching. Most recent sexual assault and rape definitions have been much more all-encompassing, recognizing that both men and women may be victims and physical force is not required, and acknowledging that people who are vulnerable-due to physical, mental, or substance-related impairments-are frequently incapable of providing consent.

	The differing definitions of sexual assault and rape from state to state, and statutes of limitations and mandatory reporting laws are listed on the Rape, Abuse & Incest National Network (RAINN) website. It is an excellent resource, but should not replace consultation with an attorney when appropriate.

	Accurately estimating the prevalence of sexual assault is challenging because the way data are collected significantly affects the reported incidence. Data from law enforcement or medical records underestimate incidence because victims frequently do not seek medical care or law enforcement assistance. Community surveys tend to report higher rates that likely provide a truer representation of the incidence of sexual assault.

 Likely less than 25% and perhaps as few as 10% of cases ever come to the attention of police.

 Similarly, healthcare providers likely care for only a very small fraction of sexual assault survivors.

	Ob/gyns must be aware of the definition, prevalence, implications, and underreporting of sexual assault. It is our responsibility to screen for assault and to provide a safe and nonjudgmental environment for disclosure.

, using quotations when possible, even if they seem fragmented or scattered. Ages and identifiers of both the patient and assailant, facts regarding time and location, any involvement of weapons or substances, and details about sexual contact and body fluid exposures also are important to include. However, avoid “playing detective” and using the words “rape” and “sexual assault” because they are legal terms.

 Instead, use phrases such as “sexual assault by history.” Focus your documentation only on the history as given by the survivor, including direct quotations, and objective findings on examination.

	While it may be appealing to use a recording device, patients may interpret that as threatening and interrogatory. Because the medical record may be used in court, documentation of factual details only (as opposed to a patient’s expressed doubts or feelings of guilt) is most beneficial (eg, do not include statements such as “the patient states that she may have had too much to drink”).

	A woman’s physical recovery and psychosocial response to assault rest in part on her immediate physical care. If the case is reported to police, physical examination and specimen collection can serve as evidence.

 To appropriately serve as evidence, the examination must be done and specimen obtained properly to show a clear chain of possession without contamination. 

	Most women who seek medical care following assault do so at emergency departments (EDs), which tend to be best equipped to handle such situations. However, some women may present to their ob/gyn’s office, where they may feel more comfortable. Regardless of where a woman presents for care, she should be evaluated first and foremost for any life-threatening injuries.

	Physicians’ offices are often not appropriately equipped with sexual assault collection kits, and examination and specimen collection in such a setting may jeopardize evidence preservation. Therefore, if there is an ED in your area, encourage patients to go there for examination and evidence collection, even if they are not certain that they wants to report the incident, because the evidence may be held securely for later release.

	“Chain of custody” refers to the chrono logical documentation of evidence, including who collected it and how, how contamination was avoided, and how it was passed to police. Because this is a critical component in legal proceedings, it is best to use pre-assembled rape kits and a collection protocol. Protocols vary and many hospitals have developed their own programs, which may involve sexual assault nurse examiners (SANE) and sexual assault response teams (SART) trained to accurately collect evidence and maintain chain of custody.

 Advocates are often involved to provide support and education. Importantly, advocates have statutory privilege so that their communications are confidential and cannot be used in a court of law.

	Rape kits can be obtained from police departments or crime labs free of charge. If you practice in an area without an ED or other facility equipped to treat sexual assault survivors, keep one or 2 kits in the clinic so that evidence collection can be performed there. The kits come with clear instructions on how to collect and package evidence.

	Obtaining the patient’s consent prior to each portion of an examination is crucial in giving her a sense of control. The first priority should be to identify and address any acute injuries. Photography or a diagram can be used to document their location and nature. A colposcope can also be useful for a more detailed examination and detection of injuries.

 Ideally, you should use a camera attached to a colposcope, with a memory card to store the digital files.

	At our institution, photos are immediately uploaded to the patient’s electronic medical record, where an audit trail can confirm validity of images. Another option is to immediately place a USB drive containing the images into the evidence collection kit for law enforcement.

	Multiple samples must be obtained in a specific manner to maintain validity as usable evidence. Foreign hairs or fibers on the survivor may support that contact occurred and help in identifying the assailant. Hair and fibers are collected in 2 manners: combing for and pulling known hairs.

 However, pulling hair samples is painful and often traumatic. Many experts recommend that hair or fibers only be collected by combing and that known hair samples be pulled later if requested by the prosecution and with the survivor’s consent.

	Historically, law enforcement has emphasized immediate examination of a wet mount of material from the vaginal fornix to inspect for presence of spermatozoa. However, this led to the misconception that if spermatozoa were not present, a sexual assault did not occur. In addition, ED examiners and forensic scientists often gave conflicting testimony regarding presence of spermatozoa. Therefore, immediate examination for sperm is not recommended. Vaginal and oral swabs, as well as blood samples, are occasionally obtained for baseline STI testing and DNA evidence that can be used for prosecution. Which swabs to obtain are dictated by the details of the assault. Baseline STI testing is indicated in all survivors who decline prophylaxis.

	Multiple studies on sexual assault have demonstrated the value of documenting physical findings and collecting biological specimens. Accurate documentation and collection allow more charges to be filed and result in higher conviction rates.

 Ob/gyns should strongly encourage survivors to undergo examination. While these procedures can be long and arduous, if they are capably performed with appropriate advocacy and support, they should never further traumatize a woman.

	Rape kits can be collected for forensic use as late as 7 days after an assault, depending on the jurisdiction.

 Beyond then, a kit cannot be used for prosecution, but survivors should still be encouraged to approach police. States and health systems have different policies regarding how long a kit can be stored, but survivors may have kits collected even if they are not certain they would like to submit them to police. The statute of limitations on pressing charges for sexual assault varies. In many states there is no time limit, whereas in others it ranges from 3 to 10 years.

	Alcohol is frequently involved in acts of sexual misconduct, either voluntarily or by coercion. However, occasionally stronger mind-altering substances (eg, flunitrazepam [Rohypnol], gamma hydroxybutric acid [GHB], or ketamine) may be covertly administered. If you or your patient suspect drug involvement, obtain a urine sample for toxicology screening.

	Evaluation of a sexual assault survivor should not differ if she is pregnant unless you are concerned that the physical trauma might jeopardize the pregnancy. Depending on gestational age and circumstances surrounding the assault, inpatient fetal or maternal monitoring may be indicated.

	Survivors often are concerned about STIs and pregnancy risks following a sexual assault. Ascertaining the risk of acquiring an STI following an assault is quite challenging, and rates vary considerably depending on demographic factors. Even if a survivor does not want to proceed with forensic examination and evidence collection, she should be offered prophylaxis (Figure 1).

	All survivors should also be offered initial laboratory testing for chlamydia, gonorrhea, trichomoniasis, syphilis, hepatitis B, and HIV, particularly if they decline to receive prophylaxis. Repeat HIV and syphilis testing is recommended at 6 weeks and at 3 and 6 months after the assault. Need for post-exposure HIV prophylaxis should be determined on a case-by-case basis and initiated within 72 hours.

	Pregnancies following sexual assault occur in approximately 5% of cases.

 Emergency contraception (ulipristal, if available, or Plan B One-Step) should be offered to all women of childbearing age after a negative pregnancy test. Emergency contraception should be considered effective up to 72 hours (Plan B One-Step) to 120 hours (ulipristal) following the event, but it is most efficacious within 12 hours.

	States have different laws and regulations regarding reporting of sexual assault, and it is important to be familiar with resources available in case of unclear situations.

 In several scenarios-most often involving a child, incest, or domestic violence-healthcare providers are required by law to report sexual assault. Each state has different laws regarding statutory rape, the age of consent, and other nuances involving mandatory reporting. Providers aren’t expected to commit to memory their own state’s laws in their entirety, but it is crucial that you know the appropriate resources to use when faced with an uncertain situation.

	Depending on the state, the decision whether to report lies in the hands of the survivor. Fear, shame, guilt, and mistrust are just a few of the reasons a woman might not disclose or report an assault. However, you should keep in mind the ramifications to public health of an assailant who is not apprehended and does not face appropriate legal repercussions, and encourage patients to report all sexual assaults.

	Balancing appropriate and thorough evidence collection with survivor advocacy is challenging. Many ob/gyns who want to spare patients evaluation in an ED may try to piece together makeshift rape kits in their offices. However, that sort of evidence collection is often unusable in a court of law. If a patient intends to report to police, evaluation in a facility that is equipped for evidence collection is crucial. Encouraging a survivor to report an assault and providing the appropriate resources for her to do so may mean greater legal ramifications for the offender.

	Referrals to counselors, mental health specialists, and medical subspecialists as appropriate are critical. Chronic health conditions and mental health concerns are common in assault survivors, and it is crucial that we help them develop a sense of wellness and support.

The authors wish to acknowledge their colleagues Joanne Bailey, CNM, and Edward Goldman, JD, who provided expertise, edits, and insight that greatly assisted in the writing of this paper.

	1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. 

National Intimate Partner and Sexual Violence Survey: 2010 Summary Report

. http://www.cdc.gov/violenceprevention/pdf/nisvs_report2010-a.pdf. (2010).

	2. U.S. Department of Justice, Federal Bureau of Investigation. 

Criminal Justice Information Services (CJIS) Division Uniform Crime Reporting (UCR) Program

. https://www.fbi.gov/about-us/cjis/ucr/nibrs/summary-reporting-system-srs-user-manual. (2013).

	3. Welch J, Mason F. Rape and sexual assault. 

	4. Young W W, Bracken A C, Goddard MA, Matheson, S. Sexual assault: review of a national model protocol for forensic and medical evaluation. New Hampshire Sexual Assault Medical Examination Protocol Project Committee. 

	5. Committee on Health Care for Underserved, W. ACOG Committee Opinion no. 592: Sexual assault. 

	6. Luce H, Schrager S, Gilchrist, V. Sexual assault of women. 

	7. Stene LE, Ormstad K, Schei, B. Implementation of medical examination and forensic analyses in the investigation of sexual assaults against adult women: a retrospective study of police files and medical journals. 

	8. Ferguson, C. Providing quality care to the sexual assault survivor: education and training for medical professionals. 

Summary of U.S. State Laws Related to Advocate Confidentiality

, <http://nnedv.org/downloads/SafetyNet/OVW/CI_USAdvocateConfidentialityStateLawChart_Oct2010.pdf> (2010).

	10. McGregor MJ, Du Mont J,  Myhr T L. Sexual assault forensic medical examination: is evidence related to successful prosecution? 

. National Protocol for Sexual Assault Medical Forensic Examinations, 2

 Edition. <https://www.justice.gov/sites/default/files/ovw/legacy/2013/04/24/safe_fact_sheet_long_final.pdf> (2013).

. Sexually Transmitted Diseases Treatment Guidlines: Sexual Assault and Abuse and STDs

. http://www.cdc.gov/std/tg2015/sexual-assault.htm (2015).

Sonia A Hovelson, MD

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After a sexual assault: A guide for the ob/gyn