Sexual Assault: The Role of the Pre-hospital Provider Tiffany Kuehl, MD Spokane Emergency Medicine Associates Deaconess Emergency Department

Objectives To be aware of the scope of the problem To become familiar with the medico-legal procedure regarding sexual assault To understand how pre-hospital providers may most effectively assist victims of sexual assault

Legal definition Rape: A person is guilty of rape by engaging in sexual intercourse with another person by forcible compulsion, or when the victim is incapable of consent by reason of being physically helpless or mentally incapacitated, or where the victim did not give verbal consent, or lack of consent was expressed through the victim’s conduct. Rape is a felony. (felony class A to class C, depending on aggression)

The scope of the problem In the state of Washington, at least one out of every three women will be victims of sexual violence during their lifetime. One in six will be raped. (source: Rape in Washington: A Report to the State) According to the WA state criminal justice Data book, there were 2772 reported rapes in In 2004 WA state community sexual assault programs served over 10,000 victims of sexual assault. (source: Office on Victim Crime Advocacy, 2004) Somewhere in America, every 2 minutes a woman is raped. (source: US Dept. of Justice)

The scope of the problem More than half of all rapes of women occur before age 18; 22% of these occur before age 12. (source: WA Dept. of Health data) At least 30% of all female homicide victims are killed by a current or former intimate partner. (source: WA Dept. of Health data) In an HMO study, abused women cost the health plan 92% more than the general female population. (source: Wisner,C.L., Gilmer,T.P., Saltzmann,L.E., and Zink,T.M. Intimate partner violence against women: Do victims cost health plans more? J. Fam. Practice 48(6):439-43)

What happens in the emergency department? Victims will go through triage and will be medically examined. They may be offered counsel with a sexual assault advocate. They will be given an opportunity to report to police. They will have the option to undergo an evidence collection process. Medications for the prevention of STDs and pregnancy will be offered.

The medical exam The medical exam establishes the presence of injury and need for treatment. In the majority of cases (70-85%) there are no visible injuries despite forcible rape. Therefore, the medical exam CANNOT reliably determine whether a rape has occurred.

The legal aspect Age of consent: A person thirteen years of age or older may request medical attention or a forensic exam without the consent of their parents. Mandatory reporting law: Any sexual assault of a minor (under age 18) must be reported to police and/or Child Protective Services. In WA, the law assumes that persons under the age of 16 are not old enough to give consent for sex. Any sexual act with someone under age 16 is defined as statutory rape.

The legal aspect If an injured victim of domestic violence is treated by a physician or nurse who does not inquire about abuse or who accepts an unlikely explanation of the injury, and the patient subsequently sustains further injury resulting from abuse, the physician or nurse could become liable for those injuries.

The sexual assault evidence collection kit It is the victim’s choice to report the crime to police and to have a SA kit done. DNA evidence is not valid 72 hours after the assault, so a kit will not be offered if more than 3 days have elapsed. The SA kit does not determine if a rape has occurred. It is used for DNA identification only.

The sexual assault evidence collection kit The SA kit goes to the custody of the police after it is complete, therefore a police report must be made in order to perform evidence collection. The SA kit is only opened/analyzed when the legal case goes to trial.

What is the SA kit? It involves collection of DNA from the victim’s body. Blood and urine is taken from the victim. Hair samples are collected. Photographs may be taken (with their permission). Cotton swabs are used to collect samples from the mouth, vagina, cervix, and anus. (depending on type of assault)

What you can do Be sensitive to the emotional state of the victim. Inform them or their rights: they have a legal right to have a support person accompany them, to have a free medical examination, and to have emergency contraception provided by the hospital. Reassure them that the information they give to medical providers will remain confidential. Reassure them that they are safe now.

What you can do Remind the victim to write down the police report number and name of the officer who took the report. Have them keep it in a secure place. Victims have the right to report to police regardless of the time that has passed after the assault. Victims do not legally have to report their immigration status to the police when reporting a crime or rape.

What you can do Don’t ask them to report the whole story to you, but if they volunteer it, document the words verbatim (use their words) and communicate to the ER staff. Protect the evidence.

Protecting the evidence Don’t disturb items at the scene before arrival of police. Document or report to ER or police regarding the scene and events. Encourage the victim to avoid showering, eating, drinking liquids, or changing clothes. Encourage the victim to bring the clothes they wore during the assault (ask victim to place items into a bag, or you use gloves), and to bring a change of clothes to the hospital.

Child sexual abuse In this case, a forensic exam may be deferred to a more specialized team. A medical exam may still be performed on those that have had a recent abuse event to assess for injury. It is important to encourage transport to ER so that home safety may be assessed.

Questions and Concerns? Have you encountered a case in which you didn’t know what to do at the scene? Are there cases you have had that you questioned? What are some biases you have witnessed? Have you felt judgmental about certain victims?

Post Test TRUE or FALSE? There are no visible genital injuries in 70-85% of rape cases. Victims have 30 days after the assault to report the incident to police. The purpose of a sexual assault evidence collection kit is to determine if a rape has occurred. One in 6 women in Washington state will be a victim of rape at some point in their lifetime. An SA kit can be performed without making a police report.

Have a Great Summer!! Renee Anderson Fax: