• Sexual assault (SA) is a crime of power and control.
• 1/3 women and 1/6 men will experience a sexual assault in their lifetime.
• 96% of perpetrators are male.
• An approach to sexual assault applies principles of trauma-informed care: safety, trustworthiness, choice, collaboration, empowerment.
• How the patient is treated at the outset (i.e. with compassion, validation and giving them their choice in their care journey) will guide their subsequent course in how they handle the trauma of their assault.
• Medical treatment is different and separate from forensics. Patients should be able to get decent medical care at any ER/UCC/FD office in BC.
• Forensics are nice if we can have it, and only if the patient wants. Forensic care is mostly only offered at specialized sites within each Health Authority.  We generally have a bit of time to get forensics, but ideally sooner the better, especially if looking for toxicology.

There are usually two aspects of care that patients are concerned about:

1. Medical: involves consideration of pregnancy risk, STI’s, injuries, and psychological well-being.

2. Forensic: involves consideration of documenting injuries and collecting potentially relevant samples for possible legal avenues, should the patient want that option.

It is the patient’s choice on what care they choose to receive.

• Call for support:
  • Contact your Sexual Assault Service (SAS) if available: all health authorities have sexual assault teams available. Consider transfer to providers trained in SA exams and forensic kits (patient decision).
  • Sexual Assault Service is available to MD’s and NP’s on the provincial RACE line 7 days per week, 0800 – 2200h provides guidance and support.

• Plan for adequate time:
  • SA assessment can take 2 to 6 hours to complete.
  • Consider calling for back-up and/or starting the assessment at the end of a shift.

• Establish a rapport based on trauma-informed principles.
  • Respond with belief, validation, and compassion.
  • Quiet, private room, not a curtained space.
  • Give power and control back to the patient by going at their pace and letting them decide what care is best for them to receive at this time.
  • Respect the patient’s choices regarding:
    • Medical care.
    • Forensic examination.
    • Involving police.

For the patient:

• Options for reporting to police:
  • Do not report.
  • Direct: from victim directly to police (there are no statute of limitations for reporting a sexual assault, so report can be made at a later date if the patient chooses).
  • Anonymous: through 3^rd party best – i.e. through a community-based organization such as WAVAW, Rape-Relief, Elizabeth Fry Society etc. EVA BC (Ending Violence Assoc. BC) has some good resources for local links.

• For the provider:
  • Duty to report to BC Ministry of Children and Families
  • Any person < 19 years old and in need of protection, including if:
    • They were assaulted by a person who is an ongoing threat to them AND
    • The patient’s family is unable or unwilling to provide protection.
  • Child protection agency, if patient:
    • < 12 years old.
    • 12 or 13, and perpetrator is > 2 years older (even if stated as consensual).
    • 14 or 15, and perpetrator is > 5 years older (even if stated as consensual).
    • < 18 years old and perpetrator is an authority figure or a family member.
    • This is the law. However respect patient’s choice not to tell you who assaulted them.
  • The assault occurred while under care (for example, nursing home).
    • Seniors Province of BC.
  •  Clear and complete documentation at every step.

A) History: the purpose of the history is to direct your medical care, and to direct your sample collection if the patient wants a forensic exam.

     Trauma-informed history-taking:

• Keep the conversation safe, contained, and connected to the present.
• Avoid extensive interviewing about details of the assault as it may retraumatize the patient and adversely affect the forensic interview.

     Components:

• Date, location, and time(s) of the assault(s).
• What is known about the perpetrator(s) including: i.e. relationship to victim, injection drug use, health status (HIV, hepatitis) – usually these are all “unknown”.
• Type and nature of sexual assault: potential exposures (penetration, condom use)
• Any loss of consciousness, memory loss or blackout – consider possible toxicological cause, head injury, or strangulation.
• Past medical history including: gynecological and sexual history, risk of pregnancy.
  • Date of LMP.
  • Vaginal intercourse since LMP (only to assess risk of already being pregnant).
  • Current contraception use.
• Medications and allergies – may interfere with meds you may need to give.
• Immunization history including B, tetanus (Hepatitis A and HPV less frequently).
• Access to support, coping strategies.

B) Physical exam: unless the patient has “red flag” symptoms (e.g. obvious physical  trauma, new genital bleeding, fever, abd pain or urinary retention) they may not need to be examined. Respect their choice to decline. Some patients will want to be examined for reassurance that they are “OK” or not damaged.

     Trauma-informed physical exams:

• No component of the examination is mandatory. The patient may consent to parts of the medical and/or forensic exam only, and they can withdraw consent at any time.
• Offer all options, explain the rationale and procedure for each.
• Tell the patient that they are in control at every step, they can say no to any question or service, and that they can stop or take a break at any time.
• Listen to and validate concerns.
• Ask if they are ready to begin. Ask permission at every step.

Tailor to patient concerns, assess injuries.

• Is never required. Only completed at the discretion, and with the consent of, the patient.
• Most Sexual Assault Services in BC offer the option of a Forensic exam up to 7 days after the assault. Each Health Authority has at least one centre that completes forensic evaluation.
• Should be completed by a provider with training in SA examination and access to SA kits (see hospitals with sexual assault services and/or call RACE line if uncertain).
• Includes:
  • Detailed history.
  • Collection of relevant samples, including body fluids, hair, textiles, trace evidence using specialized SA kits.
  • Collecting clothing worn during the assault.
  • Documentation of injuries on body-map diagrams.
  • Specialized SA teams will often complete a summary Forensic report as well.
• Once a kit has been collected the patient may choose for it to be:
  • Handed directly to police.
  • Stored for up to a year. Storage options are usually only possible when the patient has been seen by a designated SA team or service. Storage must meet chain of custody requirements.

C) Investigations: Not typically done as BC SAS premise is that this is not a “well person” check and really want to minimize trauma for our patient, so we are not going to do anything extra the patient doesn’t really need, and we are not going to ask them to come back (most SA patients shun health care afterwards). We treat all patients with prophylactic abx to treat Chlamydia and GC (Azithro 1g and Cefixime 800mg as a single dose).

• Serologies:
  • HIV Ag/Ab: If the perpetrator is known to be HIV+ or is considered “high risk” for HIV infection, contact BCCDC (604-661-7033) to discuss if HIV RNA testing.
  • HBsAg, anti-HBc, anti-HBs.
  • Syphilis EIA or RPR.
  • Anti-HCV: Optional due to low risk of sexual transmission. More strongly consider if perpetrator with known risk factors (ex. IVDU), significant traumatic lesions.

• Specimen collection:
  • BC SAS does NOT routinely do cultures as not relevant for medicolegal purposes except possibly in child protection cases where child < 12.
  • If your local SAS recommends and patient agrees:
  • Nucleic Acid Amplification Test (NAAT), cultures, and gram-stain for Chlamydia/Gonorrhea (CT/GC).
  • Consider urine NAATs sample as least invasive.
  • NAAT is most diagnostic, however cultures are preferred for medico-legal purposes.
  • Samples from all penetrated orifices (vaginal, throat and rectum) and urethra – blind vaginal swabs accepted.

• Urine pregnancy test: if possibly pregnant from before assault.

1. BCWH Sexual Assault Service
2. List of hospitals/clinics with dedicated sexual assault service teams
3. BCCDC STI treatment guidelines
4. Women Against Violence Against Women
5. VictimLink

Learning Hub course on caring for survivors of sexual assault

1. 
   

2. Subramanian S, Green JS. The General Approach and Management of the Patient Who Discloses a Sexual Assault. Mo Med [Internet]. 2015 [cited 2019 Dec 2];112(3):211.

   
   

3. Government of Canada D of J. Age of Consent to Sexual Activity [Internet]. [cited 2019 Dec 3].

   
   

4. Canadian Medical Protective Association. Age of consent for sexual activity and duty to report. 2015 [cited 2020 May 4].

   
   

5. Government of Canada Public Health Service. Section 6-6: Canadian Guidelines on Sexually Transmitted Infections – Specific populations – Sexual assault in postpubertal adolescents and adults – Canada.ca [Internet]. 2014 [cited 2019 Dec 3].

   
   

6. BC Centre for Disease Control. Dispensing prophylactic medications post-sexual assault [Internet]. 2018 [cited 2019 Dec 3]