Sexual assault: overview
Sexual offences and rape definitions vary from country to country.
Sexual Offences Act 2003 (UK)
• Rape is defined as non-consensual penetration of mouth, vagina, or anus by a penis.
• Sexual assaults are acts of sexual touching without consent. Sexual assault by penetration involves the insertion of object or body parts other than the penis into the vagina or anus (previously indecent assault).
• Children under 13 cannot legally consent to sexual activity and therefore do not need proof of consent. There is no defence in mistaken belief of age.
It is crucial that advice is sought (from the police or a sexual assault referral centre) before any examination is undertaken, to preserve possible evidence available.
Assessing a potential victim
It is important to establish:
• Whether a sexual act has occurred.
• Whether the victim gave consent when competent to give consent.
• Ability of the victim to give consent to forensic examination:
• age, understanding, language, maturity, or intoxication.
• Need for interpreters for language difficulties.
• Need for ‘appropriate adult’ for anyone under age or with mental incapacity.
Victims may present acutely but frequently there is delay which may be detrimental to evidence gathering. Acute on chronic presentation is also common, particularly with children.
Victims of acute sexual assault may report to the police directly, or to A&E, GU medicine, gynaecological, or psychiatric services with covert or overt symptoms. It is crucial to any criminal case that evidence is gathered appropriately and the chain of evidence maintained. 16–58% have genital injuries but a higher proportion (38–80%) have non-genital injuries.
Always consult with the police if there is any doubt about an individual's presentation.
Can be with a number of symptoms (recent or historical). GU medicine, gynaecology, and psychiatry are frequent specialities for disclosure of sexual assault or abuse. As there is a significant increase in domestic violence and assault during pregnancy, antenatal services must include screening and referral facilities.
Sexual assault: facts and figures
• The lifetime risk of sexual assault is 1 in 4–6 for women.
• It is estimated that only 1 in 5 adult rapes is reported.
• 1 in 10 victims of sexual assault are men.
• 12% of assaults are by strangers.
• 45% are by acquaintances and 43% by intimate partners.
• 45% involve vaginal rape, 10% anal rape, 15% oral rape, and 25% digital penetration.
• The incidence of child sexual abuse is unknown + possibly only 1 in 20–50 assaults of children are known to supervising authorities.
• The prevalence is far higher than that reflected in numbers reported.
Sexual abuse in children
Concerns for children should be heightened in association with:
• Repeated A&E attendances.
• Poor parent/child interactions or behaviour.
• Child known to social services.
• Any injuries to child under 1 year.
• History of domestic abuse.
• Explanation inconsistent with injuries.
• Disclosure of abuse by child.
• Delay in presentation.
Sexual assault: history and examination
• Consent is taken before any forensic medical examination.
• Confidentiality issues: the victim may agree to only partial release of information and samples but is able to change this decision later; forensic samples can be stored for up to 30 years or 30 years after their 18th birthday.
Key history points
• Alleged assault and what happened since including eating, drinking, showering/bathing, passing urine, opening bowels, and douching.
• Basic medical, surgical, and psychiatric history.
• Medication—prescribed, over-the-counter, social, drugs of abuse.
• Gynaecological, obstetric, and sexual history.
• Last menstrual period, menstrual cycle, contraception.
• Police will also require details of meeting place and details of assault.
Timing of the examination and sampling should be noted. The presence of pre-existing conditions such as skin problems or markers of self harm must also be documented.
Key examination points
• General findings.
• Injuries (record accurately with diagrams—photographs may be used (involvement of police photographer is favourable):
• non-genital: none, bruising, petechiae, abrasions, lacerations, incisions, defence injuries
• genital and anal: none, bruising, abrasions, lacerations, incisions, structure of hymen/remnants in those sexually active (or not)
• oral: mucosa, teeth, tongue.
• Clothes may also be important for evidence.
• Evidence kits may be available in A&E departments or brought by the police/forensic examiner. If at all possible evidence by someone trained in this procedure, to ensure the highest standard.
• Evidential samples for sexual offences are likely to be: semen, saliva, vaginal samples, urine, blood, faeces, hair, fibres, vegetation, sanitary pads and/or tampons, toilet paper, clothes, and condoms.
Key samples for reported sexual assault
• Oral intercourse: mouth swab/saliva/mouth wash ± appropriate skin swab.
• Vaginal intercourse—swabs: vulval (×2), perineal (× 2), low vaginal (× 2), high vaginal (× 1), endocervical (× 1), from speculum (× 1), lubricants ± pubic hair.
• Anal intercourse—swabs with proctoscope: perianal (×2), rectal (×2), anal (×2).
• Buccal swabs are taken for victim DNA.
• Double swabs = 1 dry + 1 wet (saline container).
• Skin samples collected within 48 hours, mouth 24–48 hours, anal 72 hours, and vaginal up to 7 days after the assault.
► Forensic examination at >7 days for women and >72 hours for men is unlikely to provide useful evidence.
Sexual assault: management
• Resuscitation/usual ‘ABC’ measures are of overriding importance.
• Consideration of collection of evidence.
• Prophylactic antibiotics.
• Post exposure prophylaxis for HIV.
• Emergency contraception.
• Hepatitis B vaccination.
• General advice and support.
• Follow-up including counselling.
This should be given if there has been any vaginal contact in women or menstruating girls, irrespective of stage of menstrual cycle. Current recommendations: levonorgestrel 1500 micrograms stat within 72 hours of sexual act or IUCD insertion with antibiotic cover within 5 days.
Sexually transmitted infections (STIs)
Risk is estimated at 4–56% depending on the local prevalence and degree of trauma. Consider prophylactic antibiotics particularly if the victim is unlikely to attend for follow-up: 1 g azithromycin + 500 mg ciprofloxacin (or follow local guidelines).
Those at immediate risk of self harm or suicide must be referred to on-call psychiatric services. Others may be referred to local counselling or support services as well as being given details of emergency out of hours contacts (see Websites and helplines, p. [link]). Counselling should aim to contain the trauma of the experience and help the victim bear the ‘unbearable’. Those with persistent symptoms after 6 months may have post-traumatic stress disorder and need referral to psychiatric services.
Child sexual abuse
It is difficult to know proportions of extrafamilial and intrafamilial sexual abuse because of under-reporting (possibly 2/3 to 1/3 respectively of reported abuse). Most children do not present acutely and may present because of Social Services or medical concerns regarding chronic physical illness/failure to thrive/neglect.
Emergency contraception must be remembered in pubescent girls.
STIs diagnostic for child sexual abuse are:
• Gonorrhoea (if over 1 year).
• Syphilis and HIV (if congenital infection excluded).
• Chlamydia (if over 3 years).
HIV and sexual assault
Risk is dependent on the prevalence in the population and trauma of assault. The prescribing of postexposure prophylaxis (PEP) must be carefully balanced against the side effects and risks of taking them. Consider the higher risk factors: assailant HIV positive or in risk group, anal rape, trauma and bleeding, multiple assailants.
• PEP: currently 3 antiretroviral drugs taken ASAP (within 1 hour if possible) and within 72 hours. An HIV test is required at baseline and 6 months. Appropriate follow-up must be arranged because of the toxicity of these drugs. There are no studies of the efficacy of PEP after sexual exposure.
Rape Crisis Federation. www.rapecrisis.org.uk (local numbers available from website)
Victim Support: for victims of all crimes including sexual assault. www.victimsupport.org.uk Tel. 0845 30 30 900
The Havens: London Sexual Assault Referral Centres. www.thehavens.co.uk
Samaritans. www.samaritans.org.uk Tel. 08457 90 90 90
Brook: helpline and online enquiry service for the under-25s. www.brook.org.uk Tel. 020 7284 6040
Rights of Women. www.rightsofwomen.org.uk Tel. 020 7251 6577
Suzy Lamplugh Trust: for issues of personal safety. www.suzylamplugh.org.uk Tel. 020 8392 1839