1. Sexual Assault Forensic Examination
Major Gwen Foster CNM
Travis AFB, CA
---All slides need to be updated---

2. Objectives Governing Policies Reporting Rules
Role of Sexual Assault Examiner
SAFE KIT

3. Sexual Assault Policies
Department of Defense Directive
Department of Defense Directive
Army Regulation , Chapter 8 and Appendix 1
AFI , Sexual Assault Prevention and Response Program

4. Reporting Rules
Restricted (Confidential)
Unrestricted

5. 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
Provide comprehensive medical attention
Perform evidentiary exam
Provide emotional support
Ensure proper and adequate referrals
Serve as expert witness

6. Forensic Examination PRIMARY ASSESSMENT SECONDARY ASSESSMENT
Physical, mental and emotional care
SECONDARY ASSESSMENT
ID, collect, preserve and document evidence
Determine if evidence consistent or inconsistent
Care, physical, mental and emotional is the FIRST goal of the medical-legal examination. The victim’s safety and medical well-being always take priority over evidence collection.
A well cared for victim will not only be able to cooperate better during the exam but may also begin the healing process sooner in a supportive environment.
A systematic approach to the exam is necessary to ensure proper and complete evidence collection occurs, to ensure holistic care is provided to the victim and to ensure evidence collection and chain of custody are not called into question during the legal phase of the case.

7. 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…
When discussing options with a victim of sexual assault and giving them the tools to make an informed decision about their care, it is important to stress the window of opportunity for collecting evidence. Explaining to the victim that they can go ahead and have the evidence collected while there is a higher likelihood of evidence being present and THEN take the time to decide if they would like to pursue the case or not (the kit will be held for 12 months in a restricted case). For example, if a victim feels they do not want to go unrestricted and does not have an exam done but six months later after counseling and receiving support, they do want to pursue an investigation it will be too late to collect any forensic evidence. That same victim who is unsure at the time of the assault but has an exam completed and then opts to report in six months will have the added benefit of any forensics and documentation that was collected during the exam. Another opportunity to leave all doors open as the victim decides what is best for them.

8. Forensic Examination (cont.)
Sperm heads - 19 days post-assault
Epithelial cells - 3 weeks post-assault
It is up to the agency performing the exams or law enforcement how far out they are willing to go time-wise on performing exams. Familiarize yourself with local policy.

9. Use physical evidence to tie the scenes together
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
Why do a forensic exam? Locard’s principle is the primary basis for forensic evidence collection. Physical evidence from the VICTIM can be linked to the SUBJECT and the scene, Physical evidence from the SUBJECT can be linked to the VICTIM and the scene. Remember, in a “he said/she said” case some of the impact of forensic evidence may be lost. If “he said” they had consensual sex, then of course you will find his DNA, hair, fibers, etc. during the exam. The exam may still be helpful however in corroborating the victim’s version of events or if the alleged perp recants and denies the contact. Better to get the exam then wish you had gotten the exam when it’s too late to collect evidence.
Helpful to explain to victim “three crime scenes” so they can understand how all the pieces fit together.

10. Evidence Transfer
What is this a picture of? Allow audience to make some guesses. Explain it was forensic evidence collected in an assault case. Next slide for follow on.

11. 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
Example of direct and secondary transfer. This is a grasshopper wing that was pieced back together. The left portion of the wing was found on the clothing of a victim of an assault (knife wound) in the Philippines. The right portion was found in the cuff of a pant leg of one of the assailants. This linked them to each other. Similar and smaller trace evidence such as fibers and hairs can also link subjects to victims.

12. Overview of the Exam Forensic interview
A sexual assault examination kit

13. Victim Interviewing Ensure safe and supportive environment
Influences –
quality of the history
cooperation during the exam
Patient attitude toward legal proceedings
By ensuring the safety and a supportive environment for the VICTIM, we allow them to begin recovering from the trauma of the event. Even if initial reporting is delayed, the VICTIM has chosen now to come forward because they need resolution. Without the VICTIM’s assistance the investigation is severely hampered. This is where you can have a real impact in the life of a victim, this is where you really make a difference. By providing a supportive environment you will help to stabilize the victim and increase the quality of evidence collected. 13

14. Primary/Secondary Assessment
Head to Toe
Inspect/photograph
Collect
Palpate
Document

15. Equipment During examination: After examination: Camera
Colposcope/anoscope
Toluidine Blue
Woods lamp
Swab dryer
After examination:
Clothing
Medications

16. 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
Remember, victims of sexual assault have had all power and control taken away from them. It is important to help the begin the healing process by giving them choices and allowing them to make decisions. A victim should never be pressured into a forensic exam. A good SANE will explain the procedures and the benefits associated with the exam so that the victim can make the choice that is right for them. A victim can also refuse any portion of the exam, just because they agree to portions of it does not mean they are required to have every step of the exam performed. A victim can opt out of the exam at any time even after it has started. As a SARC or victim advocate, having a good understanding of the exam, its procedures, benefits, pros and cons, you can better educate the victim and help them to make a well-informed decision. You can also any questions they may have and help to reduce their anxiety. If victim does not elect to have an exam, stress the benefits of a medical exam for their health. Subject information is provided just FYI.

17. Step 2 History and Assault Information
VICTIM’s statements are placed in quotations
Medical history is important for many reasons including any conditions or scarring that may be detected during the exam. Victims are asked about conditions or medications that may interfere with STD and pregnancy prevention.

18. 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.
Important to advise victim they will have to retell their story numerous times. They will have to answer many questions, often very detailed and graphic. The interview process assists the interviewer in knowing where to look for evidence and what to collect. It is also helpful in corroborating the victim’s story. For instance, if the victim states she was dragged across the carpet and there is evidence of rug burns on her heels and buttocks, this corroborates what she is saying… it is not definitive that an assault took place, it is merely another piece in the puzzle that helps to create a picture of what occurred. The examiner needs to get a complete picture of what occurred to accurately collect evidence. They will ask many open ended questions to get as many details as possible.

19. 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
The examiner should write what is said verbatim. Some of this may be difficult for the victim to have to say/relive. Ensuring the victim is prepared for these types of questions and that they understand why these questions are necessary will help them to better cope with and cooperate with the interview process.

20. Step 2 (cont.) Information to include: Vaginal/Anal contact
Oral contact
Ejaculation
Injuries inflicted upon SUBJECT
Actions following assault
Actions following the assault are critical in the evidence collection process. For instance, if the victim says she was forced to shower and scrub her entire body after the assault, that may be helpful in explaining why no forensic evidence was found on her body. It also may help explain any seeming inconsistencies, i.e. victim states he dragged her through a muddy field and raped her but there is no dirt on her body, hair or clothes. She further discloses he took her to her home after the assault and forced her to shower and wash/dry her clothes.

21. 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
Last consensual contact allows DNA of non-suspects to be eliminated. It also prevents inadvertent entry into the CODIS (combined DNA identification system). LMP is important for pregnancy prevention or if blood is seen in the vagina during the exam… is it menstrual? Medications are important for tox screens and possible adverse interactions with STD and pregnancy prevention.

22. 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
Generally, once a victim submits clothing as evidence, the clothing is not returned to the victim. If the case doesn’t move forward or, if in the case of a restricted report the victim elects to remain restricted after 12 months, the clothes may be returned. Often times, monetary reimbursement if available for victims who submit clothing or have other expenses as a result of the report. Usually a police report is required for that reimbursement. Again, familiarize yourself with local policy.

23. Photodocumentation I Camera Photography of trauma Macro ability
Use in same plane of injury
By photographing injuries, the examiner can readily convey to the court what was observed during their examination. This will serve a dual purpose… it will likely decrease the amount of testimony the examiner has to provide (a picture is worth a thousand words). Photographs can sometimes result in a plea, as very few defense attorneys are going to want severe injuries to the victim’s genitals shown to the court. Having pictures taken of the genital area can be very embarrassing to victims. Having a thorough understanding of how the photos can help will be helpful to the victim. Photos taken of injuries can also serve to corroborate a victim’s story of the events. For instance, if a victim states her attacker held her down by the wrists and she has evidence of bruising, this can serve as corroborating evidence. Victims should also be reminded that sometime bruising darkens or increases over days. If injuries are not visible at the time of the exam and they show up over the next day or two, they should contact either the examiner or law enforcement (based on reporting option used) for follow up photos. REMEMBER: a victim without injuries does not mean no assault occurred. Injuries do NOT occur in many assaults. 23

24. Step 3 (cont.) Use of Wood lamp Fluoresces semen stains
Augment marks and pattern injuries
Detect saliva and vaginal fluid

25. Step 3 Envelopes

26. Step 4 Debris Collection
Collect any debris detected, i.e. clumps in hair, grass on body, etc.
Collect any swabs taken from dried secretions
Debris collection can be good for corroboration and also tying two scenes together

27. 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
Victims may not always recall everything that occurred during the assault, it is a traumatic experience. Fingernail scrapings is a non-invasive procedure, better to err on the side of caution and take the scraping. Helpful to explain to your victim why things are being collected even if the victim does not think it makes sense.

28. Step 5 Pubic Hair Combings
Combed to collect any debris
Paper is placed beneath victim
Looking for an “unknown” sample here. Again, this is not an invasive procedure. Even if Woods lamp is negative for dried secretions or no visible debris is seen… better to collect just in case.

29. Step 6 Pulled/cut pubic hairs
Purpose is to serve as control
Recommended by some law enforcement agencies
There is disagreement about whether or not pulling or cutting of pubic hair should be exercised to collect the sample. SANEs tend to prefer cutting so as not to cause the victim unnecessary pain. Pubic hair is considered a “known sample” and is used for comparison. You can familiarize yourself with local policy so victim will know ahead of time or so you can answer any questions victim may have in this area. An educated victim will be more prepared.

30. Step 7 Vaginal swabs/smears
Inspect/Photograph
Colposcopy
Toluidine Blue dye application
Completed before speculum insertion
After external examination and photodocumentation of the the vagina and visualization of the anus is finished, a 1% Aqueous Toluidine blue dye solution can be applied to better visualize any trauma. External examination and photographing of injuries must be completed prior to insertion of speculum. This will ensure no injuries can be attributed to the examiner.

31. Photodocumentation II
Colposcope photography
External genitalia
Injuries
External
internal
anal
Toluidine Blue dye (injury enhancement)
Apply last
Repeat injury pictures
By photographing injuries, the examiner can readily convey to the court what was observed during their examination. This will serve a dual purpose… it will likely decrease the amount of testimony the examiner has to provide (a picture is worth a thousand words). Photographs can sometimes result in a plea, as very few defense attorneys are going to want severe injuries to the victim’s genitals shown to the court. Having pictures taken of the genital area can be very embarrassing to victims. Having a thorough understanding of how the photos can help will be helpful to the victim. Photos taken of injuries can also serve to corroborate a victim’s story of the events. For instance, if a victim states her attacker held her down by the wrists and she has evidence of bruising, this can serve as corroborating evidence. Victims should also be reminded that sometime bruising darkens or increases over days. If injuries are not visible at the time of the exam and they show up over the next day or two, they should contact either the examiner or law enforcement (based on reporting option used) for follow up photos. REMEMBER: a victim without injuries does not mean no assault occurred. Injuries do NOT occur in many assaults. 31

32. Toluidine Blue Dye

33. Step 8 Rectal swabs/smears
Anus should be visualized to ensure there is no trauma
Important to remember victims may be embarrassed and may not disclose all details. Better to err on the side of caution and take the sample. If the victim remembers something at a later date or feels more comfortable disclosing at a later date, it may be too lat to collect the evidence at that time.

34. Step 9 Oral swabs/smears
Non-invasive procedure, always collect
Again, victim may be embarrassed to admit oral sex occurred. Oral swab is very non-invasive, always collect.

35. Step 10 Pulled/cut head hairs
Minimum of 5 full-length hairs from each section: center, front, back, left and right sides

36. Step 11 Known Blood Samples
In addition to collecting blood for DNA comparison, blood may be collected for toxicological analysis
Different tubes used for date rape drug screen, urine is also collected for date rape drug screen

37. Step 12 Anatomical Drawings
Document location of all injuries
Narrative descriptions should corroborate documentation

38. Sexually Transmitted Diseases
Pre-testing is not advised, results may be admissible in court
STD cultures are not part of forensic exam
Treatment Protocols
Vary from program to program
Not 100% effective
Give information on how and when to follow-up for care and STD testing
Signs and symptoms to report
STDs do not show up immediately. Victims should follow up with a medical provider 4-6 weeks following an assault. Medications can be given within 72 hours of assault. Protocols will differ from program to program. Check with your local hospital, med group or rape crisis center for the policy at your location. You can then inform the victim of treatment options available. Many STD antibiotics are given in one or two large doses. HIV prophylaxis is a much lengthier course and requires strict compliance. Hepatitis exposure may result in series of vaccines.

39. 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
Gonorrhea, chlamydia,trichomonas

40. 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

41. Pregnancy Prevention This is prevention not pregnancy termination
Emergency contraception used to prevent pregnancy following unprotected intercourse
Testing is not done to see if victim is pregnant from assault that just occurred, it is too soon to test for that. Testing is done to ensure victim is not already pregnant from a previous sexual encounter and unaware of the pregnancy.

42. 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

43. 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

44. Follow up (cont.) After patient has left Give evidence to investigator
Write report
DOCUMENT, DOCUMENT, DOCUMENT
Do not draw legal conclusions
Allow specimens to dry
Give evidence to investigator
Proper chain of custody

45. Finishing the Examination
Proper sealing and documentation on the kit are essential to maintaining chain of custody and admissibility in court. 45

46. 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)

47. Questions

48. References
Distress and Pain During Pelvic Examinations: Effect of Sexual Violence. Obstetrics & Gynecology. 112(6): , December 2008.
Olshaker, J., Jackson, C., Smock, W. Forensic Emergency Medicine (2nd ed). Lippincott, Williams & Wilkins. Philadephia, PA 2006.