Sexual Assault Forensic Examination Major Gwen Foster CNM Travis AFB, CA Objectives Governing Policies Reporting Rules Role of Sexual Assault Examiner SAFE KIT Sexual Assault Policies Department of Defense Directive 6495.01 Department of Defense Directive 6495.02 Army Regulation 600-20, Chapter 8 and Appendix 1 AFI 36-6001, Sexual Assault Prevention and Response Program Reporting Rules Restricted (Confidential) Unrestricted Role of Sexual Assault Examiner Diagnosis and treat within scope of practice Head to toe assessment ID, collect, preserve and document evidence and maintain chain of custody Refer for appropriate treatment and follow-up Provide expert testimony in a court of law Forensic Examination PRIMARY ASSESSMENT Physical, mental and emotional care SECONDARY ASSESSMENT ID, collect, preserve and document evidence Determine if evidence consistent or inconsistent Forensic Examination (cont.) Within 72 hours Yields the highest quality evidence After 72 hours Significant healing of trauma Trace evidence may be lost through natural processes and or actions of the individual being examined But… Forensic Examination (cont.) Sperm heads - 19 days post-assault Epithelial cells - 3 weeks post-assault Evidence Transfer Locard’s Principle of Evidence Transfer partial transfer of material from one to the other Minimum of Three Crime Scenes Victim Suspect Location of crime Use physical evidence to tie the scenes together Evidence Transfer Evidence Transfer (cont.) Trace Evidence: small pieces of evidence Direct (Primary) Transfer Direct contact between suspect/victim/scene Indirect (Secondary) Transfer Carried from location to other locations Overview of the Exam Forensic interview A sexual assault examination kit Victim Interviewing Ensure safe and supportive environment Influences – quality of the history cooperation during the exam Patient attitude toward legal proceedings Primary/Secondary Assessment Head to Toe Inspect/photograph Collect Palpate Document Equipment During examination: Camera Colposcope/anoscope Toluidine Blue Woods lamp Swab dryer After examination: Clothing Medications Step 1 Authorization Victims: Must agree to exam If refuse, encourage to have medical exam Subjects: Not necessary if taken under search authority or warrant AFI 44-102 188.8.131.52. Step 2 History and Assault Information VICTIM’s statements are placed in quotations Step 2 (cont.) Interview History is critical Guides subsequent examination for forensic evidence Corroborates physical findings Use open-ended questions - avoid yes and no Tell me what happened. What happened next? Tell me about the bruise on your face. Step 2 (cont.) Information to include: Identifying data Date and time of assault Number of attackers, weapons used, exact threats, restraints Location of the assault Position of VICTIM during assault Sequence of contact and penetration Step 2 (cont.) Information to include: Vaginal/Anal contact Oral contact Ejaculation Injuries inflicted upon SUBJECT Actions following assault Step 2 (cont.) Pertinent past medical history: Last Menstrual Period (LMP) Last consensual sexual contact (identify partner) Medication use Alcohol and drug use by SUBJECT and VICTIM Step 3 Clothing/Foreign material Seal each bag and label it One paper bag for each piece of clothing VICTIM will completely disrobe Have a gown ready Inspect/Photograph Examine with a Wood lamp Photodocumentation I Camera Photography of trauma Macro ability Use in same plane of injury Step 3 (cont.) Use of Wood lamp Fluoresces semen stains Augment marks and pattern injuries Detect saliva and vaginal fluid Step 3 Envelopes Step 4 Debris Collection Collect any debris detected, i.e. clumps in hair, grass on body, etc. Collect any swabs taken from dried secretions Step 4 (cont.) Collect scrapings from underneath the victim’s fingernails Useful if the victim fought off the offender Recommended to collect even if no report of having fought back Step 5 Pubic Hair Combings Combed to collect any debris Paper is placed beneath victim Step 6 Pulled/cut pubic hairs Purpose is to serve as control Recommended by some law enforcement agencies Step 7 Vaginal swabs/smears Inspect/Photograph Colposcopy Toluidine Blue dye application Completed before speculum insertion Photodocumentation II Colposcope photography External genitalia Injuries External internal anal Toluidine Blue dye (injury enhancement) Apply last Repeat injury pictures Toluidine Blue Dye Step 8 Rectal swabs/smears Anus should be visualized to ensure there is no trauma Step 9 Oral swabs/smears Non-invasive procedure, always collect Step 10 Pulled/cut head hairs Minimum of 5 fulllength hairs from each section: center, front, back, left and right sides Step 11 Known Blood Samples In addition to collecting blood for DNA comparison, blood may be collected for toxicological analysis Step 12 Anatomical Drawings Document location of all injuries Narrative descriptions should corroborate documentation Sexually Transmitted Diseases Pre-testing is not advised, results may be admissible in court Treatment Protocols Vary from program to program Not 100% effective Give information on how and when to follow-up for care and STD testing STD cultures are not part of forensic exam Signs and symptoms to report STD Prophylaxis CDC Recommendation Ceftriaxone 125 mg IM in a single dose PLUS Metronidazole 2 g orally in a single dose PLUS Azithromycin 1 g orally in a single dose OR Doxycycline 100 mg orally twice a day for 7 days Additional Follow-up Issues Refer to counseling HIV and HBV testing are recommended and are available free of charge at appropriate locations All patients should be urged to follow-up with testing if symptoms develop Pregnancy Prevention This is prevention not pregnancy termination Emergency contraception used to prevent pregnancy following unprotected intercourse Emergency Contraception Should be given within 72 hours of assault for effective prophylaxis Medication given in two doses 12 hours apart Should be advised to follow up if regular periods do not resume Instruct patient to contact ER if any severe side effects Common Dangerous Follow up Victim should follow up with medical provider if anything just doesn’t “seem right” Follow up information for counseling services SARC/Victim Advocate Follow up (cont.) After patient has left Write report DOCUMENT, DOCUMENT, DOCUMENT Do not draw legal conclusions Allow specimens to dry Give evidence to investigator Proper chain of custody Finishing the Examination Implications Patient is the Crime Scene “Evaluation must be documented…for possible use in future legal actions” “Consequence to patient, accused, hospital and provider may result from a failure to do so” (Smock ,2006) Questions References http://www.brooksidepress.org/Products/Military_ OBGYN/Textbook/Assault/Assault.htm http://www.cdc.gov/std/treatment/2006/sexualassault.htm http://www.safeta.org/ http://www.sapr.mil/ Distress and Pain During Pelvic Examinations: Effect of Sexual Violence. Obstetrics & Gynecology. 112(6):1343-1350, December 2008. Olshaker, J., Jackson, C., Smock, W. Forensic Emergency Medicine (2nd ed). Lippincott, Williams & Wilkins. Philadephia, PA 2006.