Sexual assault

Question 1

Sexual assault - definition

Answer 1

1. Rape: is defined as non-consensual penetration of mouth, vagina, or anus by a penis.
2. 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).
3. Children under 12 cannot legally consent to sexual activity and therefore do not need proof of consent. Mistaken belief of age is not a valid defence.

Question 2

Sexual assault - assessment of potential victim

Answer 2

1. Whether a sexual act has occurred. If yes, when it occurred
2. Ability of client to give consent to forensic examination: age, understanding, language, maturity, injury, or intoxication
3. Need for interpreters, ‘appropriate adult’, or advocate if intellectual disability
4. Need of assessment for any acute psychiatric or physical symptoms must always take precedence over forensic examination if needed
5. If reported to the police or victim wants to report it to the police

Question 3

Sexual assault - presentation

Answer 3

1. Acute
2. Delayed
3. Acute on chronic (common, especially with children)

Question 4

Sexual abuse in children - causes for concern

Answer 4

1. Disclosure of abuse by child
2. Poor parent–child interactions or behaviour, or history of domestic abuse
3. Repeated A&E attendances, or child known to social services
4. Explanation inconsistent with injuries, or delay in presentation
5. Any injuries to child under 1yr

Question 5

Sexual assault - history (?)

Answer 5

1. Written consent
   - Taken before any forensic medical examination
   - Ages for consent to examination in Victoria?
2. Confidentiality issues
   - Victim may agree to only partial release of information and samples, but is able to change this decision later (?)
   - Storage of information in Australia?

Question 6

Sexual assault - examination

Answer 6

Performed by who? At the same time as a gynaecological/general examination (e.g. in ED or in theatre)

1. Demeanour, intoxication.
2. Height, weight, BP, pulse, temperature
3. General findings, including pre-existing conditions such as skin problems, or markers of self-harm
4. Injuries (record accurately with diagrams—photographs may be used (involvement of police photographer is preferred):
   a. Non-genital: none, bruising, petechiae, abrasions, lacerations,
   incisions, defence injuries
   b. Genital and anal: none, bruising, abrasions, lacerations, incisions,
   structure of hymen/remnants in those sexually active (or not)
   c. Oral: mucosa, teeth, tongue
5. Clothes may also be important for evidence

Question 7

Sexual assault - collection of samples

Answer 7

1. Oral intercourse: mouth swab, saliva, mouth wash +/– appropriate skin
   swab
2. Vaginal intercourse—swabs: vulval and perineal (both ×2 ), low vaginal ( × 2), high vaginal with a Cuscoe’s speculum ( × 2), endocervical ( × 2),
   from speculum ( × 1).
3. Lubricant used is also sent.
4. Anal intercourse—swabs: perianal (× 2 ), rectal (× 2 ), and anal (× 2 ) with proctoscope
5. Buccal swabs are taken for victim DNA
6. Double swabs = 1 dry + 1 wet with saline as these have shown the best return of DNA.
7. Fingernail (× 2 ) and hand (× 2 ) swabs and skin ( ×2 from each site) if stranger assailant.
8. 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.
9. Blood and urine for toxicology should be taken 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

Question 8

Sexual assault - mx

Answer 8

1. Emergency contraception - should be given if there has been any vaginal contact in women or menstruating girls. Current recommendation = levonorgestrel 1.5mg witin 72h of sexual act, or IUD insertion with antibiotic cover within 5d
2. Sexually transmitted infections - consider prophylactic antibiotics. STI screening 2 weeks after assault is recommended. HBV vaccine should be discussed and given where indicated. PEP of HIV should be considered and discussed
3. Psychological care - those at risk of self-harm or suicide must be referred to on-call psychiatric services. Others may be referred to local counselling or support services
4. Referral to social services if child sexual abuse
5. Analgesia, consideration of collection of evidence