Triage and Intake

  • A sexual assault patient (hereinafter referred to as patient) should be considered a priority patient–regardless of whether additional physical injuries are evident.
  • Whenever practicable, provide a private area, such as a private treatment room, in which the patient can await both intake and treatment.
  • If possible, wait until the sexual assault counselor arrives before beginning the exam.
  • Avoid exposing the patient to places and situations which may cause her/him to suffer further emotional stress. Keep in mind the fears and disorientation which the patient may be experiencing.
  • Ask the patient if there is someone that s/he would like to have contacted, or anything that s/he needs at that time.
  • Exercise discretion and sensitivity when discussing a sexual assault victim or the family with other personnel (e.g., when summoning specialized personnel or when transporting evidence collection materials to an examination room).
  • Explain to the patient that urinating, rinsing mouth, showering, etc. may destroy evidence prior to collection. If a patient must go to the bathroom, warn her/him that semen or other evidence may be present in pubic, genital, and rectal areas, and not to wash or wipe away those secretions until after the examination.

The State of Connecticut, Office of Victim Services, Gail Burns-Smith Sexual Assault Forensic Examiners Program (SAFE Program)

  • Hospitals participating in the SAFE Program use the following protocol for triaging patients
    • Triage should call the on-call SAFE at: (860) 263-0190. If triage is unable to reach the on-call SAFE or if there are any questions, call the Program Coordinator: (860) 748-3706.
    • The SAFE nurse will then call the local sexual assault crisis services program to activate an advocate.

Counseling and Support

  • Call the local sexual assault crisis services program as soon as the patient arrives at the emergency department. See page X for a list of programs.
  • When the advocate arrives, notify the patient that confidential sexual assault counseling services are available at no charge and that an advocate is at the hospital.
  • With the patient’s consent a sexual assault counselor should be allowed to accompany the patient throughout the exam.
  • If a victim’s clothes will be collected as part of the evidence collection, notify the sexual assault counselor, who may be able to provide clothing for the victim to wear upon discharge.

Sensitivity

  • Keep in mind that the evidence collection exam is likely to be the first significant physical contact that a patient will have following an assault.
  • Treat the patient with dignity and respect. Introduce yourself, acknowledge the trauma s/he has experienced, and explain the exam process.
  • Ask the patient for permission before touching her/him in any way.
  • Give the patient time to respond; try not to rush her/him.
  • Use open-ended questions such as, “what, how, where, tell me…, describe…” Avoid “why” questions.
  • Avoid judgmental responses and facial expressions.
  • Avoid use of the word “alleged” as it tends to creates the impression that you are doubtful about the patient’s truthfulness. Instead of recording “alleged sexual assault” as the chief complaint, simply record “sexual assault.” Instead of recording, e.g., “patient alleges” or “patient claims,” indicate that the “patient states…” Under “Impression/Diagnosis” use “sexual assault by history,” or “examination and history consistent with patient’s chief complaint of sexual assault.
  • Allow the patient to regain control and to make her/his own decisions.
  • Remember that although caring for sexual assault patients may be a routine procedure for medical personnel, a sexual assault is a traumatic, life changing event for the patient.

Translation Services and Cultural Concerns

  • Ensure that patients whose first language is not English have access to sensitive translation services.
  • Be aware that a patient with a speech problem may prefer communicating through an intermediary who is familiar with the patient’s speech patterns. If the intermediary assists with the communication of information recorded in the medical record, be sure to record the intermediary’s name, address and telephone number in the signature section of page four of the Medical Report. (See page 25).
  • Provide a sign language interpreter when necessary.
  • Be tolerant of patient’s language skills and communication barriers, which may be worsened by crisis.
  • Be familiar with the cultures in your community in order to build an awareness and appreciation of them, so that your actions and demeanor will help to mitigate rather than exacerbate the trauma.
  • Understand that some patients may be apprehensive about service providers from cultural backgrounds different from their own.
  • Be aware that discussing sexual assault or sexual terms may be associated with shame and embarrassment in some cultures, and that in some cultures the loss of virginity is devastating.
  • Recognize that beliefs about women, men, sexuality, sexual orientation, race, culture, religion, and sexual assault may be very different among patients – never assume anything.

Sexual Assault and Drug Ingestion

  • Alcohol, drugs and other substances are sometimes used to sedate or overpower victims. In recent literature, the most frequently used drugs, commonly referred to as “date rape drugs,” are Rohypnol, Gamma Hydroxyl Butyrate (GHB), and Benzodiazapines, although other drugs may also be utilized.
  • Often, these drugs are mixed with alcohol and/or other beverages to incapacitate the victim, usually without the victim’s knowledge. Once the victim recovers from the effects of the drug, retrograde amnesia may make it difficult to recall events. Consequently, sexual assault victims may not be aware of the assault or even of how they were drugged.
  • Signs and symptoms of drug facilitated sexual assault include drowsiness, lightheadedness, dizziness, fatigue, decreased blood pressure and memory loss. Some of these symptoms may last several days.
  • The examiner should be aware of the possibility of the use of these drugs or other drugs and discuss this with the patient. The patient should be asked to describe any symptoms that may indicate the use of a drug and, if indicated, the examiner should offer to collect samples for a blood and/or urine toxicology screen for the presence of such drugs in the patient’s body.
  • Rohypnol, Benzodiazapines, and GHB generally can be detected in the blood anywhere from 4-36 hours after ingestion and in the urine up to 72 hours after ingestion.

Deciding Whether/When to Test

In any of the following circumstances, the possible evidentiary value of collecting a blood and/or urine sample for the identification of drugs should be discussed with the sexual assault patient:

  • If the patient or accompanying person (e.g., family member, friend or police officer) states the patient was or may have been drugged;
  • If the patient suspects drug involvement because s/he has no recollection of the event(s);
  • If, in the opinion of the examiner, the patient’s medical condition appears to warrant toxicology screening for optimal patient care and/or evidentiary purposes (e.g., patient presents with drowsiness, lightheadedness, dizziness, fatigue, decreased blood pressure, memory loss, impaired motor skills, etc).
  • Blood and/or urine sample collection for toxicology testing should be done only with patient consent. In order for the patient to give informed consent, discuss the following information with the patient. It may be helpful to involve a sexual assault crisis counselor in such discussions.
    • The ability to detect and identify any drugs present depends on collection of blood and/or urine within a very limited time period following ingestion.
    • There is no guarantee that testing will yield positive results.
    • Testing is not limited to so-called “date-rape drugs” and may reveal other drugs that the patient may have voluntarily ingested.
    • Failure or refusal to undergo testing when indicated by circumstances as described above may negatively impact any criminal investigation and/or prosecution.
  • If the patient consents to toxicology screening, samples should be collected even if the patient is undecided about reporting the assault to the police. (See page 19 of the Technical Guidelines for “Control Number” instructions in such circumstances. Samples should be transported according to transfer procedures set out on page 62)

 

Consent for Toxicology Testing

  • Testing for the presence of drugs and/or alcohol in the system of a sexual assault patient is not suggested or required unless medically indicated or indicated by the patient’s case history.
  • Fully review the Consent for Toxicology Screen form with the patient in order to help the patient understand to what s/he is consenting. If the patient consents to testing, retain signed form in patient’s medical record.
  • If the decision is made to collect samples for toxicology testing:
  • Collect blood sample at the same time as Step 1 of the CT100 Sexual Assault Evidence Collection Kit (See page 35);
  • Collect urine sample after all steps of the CT100 Sexual Assault Evidence Collection Kit have been completed.
  • If the patient consents to toxicology testing, samples should be collected even if the patient is undecided about reporting the assault to the police.
  • Hospital labs should not generally be used for forensic toxicology testing. Samples should be collected using the CT 400 Kit and sent to the crime lab for analysis.

 

Special Concerns Regarding Elderly Patients

  • Elderly patients will likely experience extreme humiliation, shock, disbelief and denial just as other patients do, but in addition, usually also must confront an acute awareness of their physical vulnerability, reduced resilience and mortality.
  • Fear, anger or depression can be especially severe in older patients who often are isolated, have no support system and live on meager incomes.
  • Be aware that elderly patients may be victims of abuse perpetrated by their caretaker(s).
  • Because generally the elderly are physically more fragile, in addition to possible pelvic injury and STIs, the elderly may be more at risk for other tissue or skeletal damage and exacerbation of existing illnesses and vulnerabilities. Their injuries also are more likely to be life-threatening.
  • Hearing impairment and other physical conditions attendant to advancing age, coupled with the initial reaction to the assault, may render the elderly patient unable to make her/his needs known. Take care not to mistake this confusion and distress for senility.
  • Every effort should be made to provide necessary assistance to elderly patients. Medical and counseling follow-up services should be made easily accessible, otherwise older patients may not be willing or able to seek or receive assistance.
  • Without encouragement and assistance in locating services, older patients may be reluctant to proceed with the prosecution of their offenders.
  • See page 14 and consult your facility guidelines regarding mandatory reporting requirements when the patient is age sixty or older. (See Appendix E for sample forms).

 

Special Concerns Regarding Patients With Disabilities

  • Patients with disabilities may have limited mobility, cognitive problems or difficulties which impair perceptual abilities, impaired and/or reduced mental capacity to comprehend questions, or limited language/communication skills to tell what happened. They may be confused, frightened, unsure of what has occurred, or they may not even understand that they have been victims of crime. Every effort should be made to provide necessary assistance for patients with disabilities.
  • If speech problems are evident, ask the patient if s/he has or would like a word board or speech synthesizer, or other assistive device. Provide a sign language interpreter whenever necessary.
  • Allow additional time as necessary for evaluation and for the medical and evidence collection examination.
  • A patient with physical disabilities may need special assistance to assume the positions necessary for a complete medical and evidence collection examination. Allow the victim to control getting on/off the exam table. Modification of normal procedures may be indicated in some instances.
  • The use of anatomically-correct dolls by specially trained personnel has proven to be a successful method of communication for patients with communicative disabilities.
  • See page 13 and consult your facility guidelines regarding mandatory reporting requirements when the patient is an adult with mental retardation. (See Appendix E for sample forms).

Special Concerns Regarding Children

  • Child victims of sexual abuse/assault present with many special needs. Please see pages 52 through 54 for a detailed discussion about the care of child and adolescent victims.

 

Special Concerns Regarding Male Patients

  • Male victims of sexual assault present with several needs specific to their gender. Please see pages 55 through 56 for a detailed discussion about the care of male sexual assault patients.

 

Mandatory Reporting Requirements

In Connecticut, there are several laws which require certain health care providers/personnel to file reports when a patient or her/his injuries meet certain criteria. Those criteria include, but are not limited to cases where the patient:

  • Is a child (CGS § 17a-101, et seq.)
  • Is a patient in a nursing home (CGS § 17b-407)
  • Is an elderly person (CGS § 17b-451)
  • Also suffers a gunshot wound (CGS § 19a-490f)
  • Is an adult with mental retardation (CGS § 46a-11c)
  • Health care personnel should be familiar with the facility’s mandatory reporting policies and procedures, and should make a report accordingly. The information presented in these technical guidelines is intended to serve only as a guide and is not an exhaustive account of mandatory reporting laws and/or procedures.
  • See Appendix E for additional information and sample forms.

Consent for Police Notification

  • Notify the police of the sexual assault only with the patient’s consent (unless the patient meets  mandatory reporting criteria). See child/adolescent section (Pages 52-54)
  • Only verbal consent for police notification is needed. Respect the patient’s right to change her/his mind at any time. (See below for additional information regarding consent).

 

Consent for Medical Exam and Evidence Collection

  • Consent for medical exam and collection is needed.
  • Review the “Authorization for the Sexual Assault Medical Exam and Release of Payment Information” form with the patient.
  • Respect the patient’s right to change her/his mind at any time before or during the examination.
  • Briefly describe the evidence collection and examination process in order to help the patient understand what s/he is consenting to.
  • Notify the patient at initial processing that s/he will not be charged for either the cost of the Kit or the completion of the Kit, even if s/he is undecided about whether to report the assault to police. (See page 69 for more information). Explain that s/he may be responsible for other medical expenses associated with her/his medical treatment, but also may be eligible for help with those expenses through the Office of Victim Services Compensation Program. (See page 74).
  • Follow your facility’s usual procedures for obtaining consent where the patient is a minor, mature minor, or a person with a cognitive disability.
  • Follow your facility’s usual procedures for obtaining consent in extraordinary cases (e.g., for severely injured or incoherent, including drugged or intoxicated, patients). Any patient who presents with a complaint of sexual assault shall be given the opportunity to provide informed consent to the sexual assault forensic exam prior to discharge.
  • There is no requirement that police be notified in order for evidence to be collected. If the patient consents, evidence can and should be collected as deemed appropriate, even if police are not notified at that time.
  • Note that police should not be present in the examining room during evidence collection. (See page 29).
  • If the patient is undecided about whether to report to police, explain the importance of prompt evidence collection, and that the evidence can be held for 60 days to give her/him time to decide. Explain also that during the 60 day period the evidence will be identified by a control number-not her/his name. (See page 19 for information regarding the creation and use of a control number).

Victim Assistance Information for Patients

  • Notify the patient as soon as possible after s/he arrives that the confidential services of a sexual assault crisis counselor are available free of charge. Make initial contact with local sexual assault crisis service. (See Appendix D)
  • Notify the patient as soon as possible that s/he will not be responsible for the cost of the medical exam or collection of evidence, but may be responsible for other related expenses.
  • Notify the patient as soon as possible that s/he may be eligible for financial assistance through the Office of Victim Services Compensation Program. (See page 74)
  • Notify the patient that assistance, including shelter, may be available if family violence is involved. (See page 74)