Ability to consent to a sexual assault medical forensic examination in adult patients with serious mental illness

When a patient reporting a sexual assault (SA) presents with signs and symptoms of serious mental illness (MI), medical providers or forensic examiners may have concerns regarding the ability to legally consent to a sexual assault medical forensic examination (SAMFE). Numerous encounters have occurred where a SAMFE was not offered to a cooperative adult patient because the patient exhibited signs and symptoms of MI. Medical providers and examiners may be motivated by beneficence (believing that treating the patient's MI must take priority over the SAMFE) and/or non-maleficence (a concern that the in-depth SAMFE may worsen the patient's psychological state). Situations where a patient has received psychiatric medications or is under involuntary psychiatric detention also raise capacity to consent to SAMFE concerns. This review explored these concerns and provides recommendations for conducting SAMFEs in adult patients with MI. In instances where a patient has the capacity and is cooperative, the decision to undergo, postpone, or decline a SAMFE ought to be ultimately made by the patient, rather than on their behalf by the provider, SANE or forensic examiner.     

Genital piercings in the context of acute sexual assault

After an acute sexual assault, children and adolescents often present for medical evaluation and treatment. Physicians have an important role in both the medical and legal components of these cases. Careful physical examination and questioning are important in determining the origin of the trauma. In the presented case report, genital trauma after an acute sexual assault was noted and attributed to the alleged offender's penis piercing. The genital trauma caused by the piercing provided physical evidence linking offender to victim and may have implications for the victim's risk of HIV infection and other blood borne pathogens.     

An approximation to the identification of contexts,experiences, and profiles of victims of drug-facilitated sexual assaults

This study advances on overcoming a bias limiting the forensic cases studies of drug-facilitated sexual assaults: a narrow study focus, restricted to assaults affecting young women in leisure contexts related to nightlife, party culture, and dating. A new working framework is applied to analyse data from cases received in the National Institute of Toxicology and Forensic Sciences (Madrid, Spain) over the six years between 2012 and 2017. The work throws light on non-previously described contexts, experiences, and profiles of victims, including domestic cohabitation, labour, education, healthcare, women trafficking, and the daily life of people with intellectual disabilities.     

Medico-legal approach to sexual assault victims: the Belgian situation

Clinical forensic medicine is a relatively new discipline in Belgium although (sexual) violence has been around for centuries. A brief overview of the Belgian legal system and the way it interacts with forensic medicine is presented, with special emphasis on the investigation of complainants of sexual violence. The epidemiology of sexual violence in Belgium is discussed together with the procedures that were developed by the government to standardise the medical examination of sexual assault victims.     

Facilities for complainants of sexual assault throughout the United Kingdom

BACKGROUND: A sexual assault referral centre (SARC) is a model of service established to address the forensic and therapeutic needs arising following sexual assault. As yet, only a minority of urban areas in England are served by one, the rest of the United Kingdom (UK) being served by police victim examination suites. OBJECTIVE: To examine variations in service offered to complainants of sexual assault within the United Kingdom in 2005. METHODS: A purpose designed questionnaire sent to all areas of the United Kingdom. Data were received and analysed from 12 of 13 SARCs and 54 of 58 non SARC services. RESULTS: Very wide disparities in service, most marked between SARC and non SARC services. SARCs see a proportion of complainants from non-police sources. The non SARC services do not usually offer a forensic examination without police involvement, and a significant minority have so few doctors that they cannot provide a 24h rota for examinations. Inadequate numbers of forensic physicians are available for child examinations, and a robust service for 'acute child sexual assault' is virtually absent. Photodocumentation with appropriate safe storage is available in all SARCs, while 45% of non SARCs have no facility for photodocumentation. DNA contamination issues were perceived to be significant in many of non SARC services. Most non SARC services for adults do not provide baseline screening for sexually transmitted infection (STI) or offer prophylaxis against STIs. Follow up is by referral to local clinics which complainants may have to arrange themselves. Funded counselling is rare in the non SARCs with the exception of Yorkshire. CONCLUSION: In the non SARC services, lack of co-operative working with local health services, lack of equipment, and lack of 'in house' medical follow up arrangements is the norm. Many areas rely on the good will of a small number of doctors to provide a service without a rota.     

The (in)significance of genital injury in rape and sexual assault

The forensic significance of genital injury following rape and sexual assault has been the subject of considerable academic and research interest, in terms of the contribution it may provide to the body of evidence in criminal proceedings. This essay takes a critical look at such research, in the context of modern understandings of what actually constitutes rape and sexual assault. Written from the author's perspective as a forensic physician practising in Scotland, it illustrates the fascinating interface between medical evidence and the legal system.     

Acoustic trapping of sperm cells from mock sexual assault samples

We report the successful separation of sperm cells from a relevant composition of mock sexual assault samples using a novel acoustic differential extraction (ADE) technology. A multi-layer microfluidic device fabricated in a non-photolithographic process from glass and polydimethylsiloxane (PDMS) was capable of interfacing with custom-built instrumentation to exploit a standing acoustic wave for the trapping of individual sperm cells in a sample containing an abundance of epithelial cells. Samples were generated from buccal and vaginal swabs to mimic post-coital vaginal swabs, and processed through the ADE system followed by DNA extraction of the captured cells with amplification of DNA using a custom short tandem repeat (STR) chemistry. The prototype acoustic trapping technology was fully capable of isolating intact sperm cells from mock samples with disparate masses of male and female DNA. Other biological components were evaluated for adverse effects on sperm cell trapping, including blood, yeast, and bacteria (E. coli), and these had negligible effects on observed sperm cell trapping. Finally, we demonstrate the successful capture of sperm cells from mock samples containing a 40-fold excess in female epithelial cells over sperm cells. The effectiveness of sperm cell purification was ascertained with polymerase chain reaction (PCR) amplification of STR loci from the male fraction post separation with an 18-plex amplification kit, which resulted in male-only profiles.     

Adolescent complainants of sexual assault; injury patterns in virgin and non-virgin groups

INTRODUCTION: Misconceptions about the likelihood of sustaining injuries following rape or sexual assault can have a detrimental effect on the justice process. This is particularly noticeable with regard to first time intercourse. Forensic physicians have a duty to put any examination findings in context. This study sets out to compare the findings in virgin and non-virgin adolescents seen at the St Mary's Sexual Assault Referral Centre, after an allegation of non-consensual intercourse. METHODOLOGY: The records of all females aged 12-17 years old, examined in an 18 month period were reviewed. RESULTS: Two hundred and twenty-four clients fitted this group with a mean age of 14.8 years. Eighty-one were "virgins" and 97 had been sexually active prior to the assault. The virgin group took longer to present for examination then the non-virgin group (90 h compared to 44 h). Of all clients 51% had a non-genital injury. These tended to be minor. 32% of the non-virgin group had a genital injury. In the virgin group, 53% had a genital injury, however only 32% had the type of genital injury that would leave permanent evidence of penetration (i.e. if examined several weeks or more later). Alcohol use prior to assault was common. CONCLUSIONS: Genital and or body injuries are not routinely found in adolescents after an allegation of rape or sexual assault even when there has not been previous sexual experience. The absence of injury does not exclude the possibility of intercourse, whether with or without consent.     

Alcohol consumption as a risk factor for sexual assault: A retrospective analysis

The aim of this study was to establish whether there is a correlation between alcohol consumption and reported sexual assaults among young people in the UK. A retrospective analysis of all cases between 01/05/2011 and 30/04/2012 involving complainants between the ages of 12 and 25 was carried out at the Lancashire SAFE Centre. In total 286 cases were included. Case notes were audited for evidence of alcohol consumption by the complainant in the 24 h prior to their assault. Further information regarding amount of alcohol consumed and any other drugs involved was also collected. In total it was found that 70.6% of complainants had consumed alcohol before being assaulted. This percentage was noted to vary with the complainant's age, ranging from 0% (age 12) to 100% (age 24). Of those who had consumed alcohol, complainants in 76.2% of cases had drunk more than the recommended daily alcohol intake, and almost a third had also taken drugs. There was only one case of suspected covert drug administration, and one forcible drug usage; in all other cases alcohol or drugs were taken voluntarily. Stranger rape (including where the complainant had known the assailant only briefly, such as meeting them the same day) was more common in complainants who had consumed alcohol. In summary, alcohol consumption often precedes sexual assaults among young people in the UK. This study therefore recommends the more widespread use of public awareness campaigns to highlight the risk of rape associated with excessive alcohol consumption.     

A case of drug-facilitated sexual assault by the use of flunitrazepam

This article presents a case of drug-facilitated sexual assault on a female intoxicated with flunitrazepam. The male assailant added flunitrazepam (1 mg) to the female's soft drink, and had sexual intercourse with her while her consciousness was impaired. The complainant did not recall the events due to benzodiazepine-induced anterograde amnesia. The use of flunitrazepam was uncovered when its major metabolite, 7-amino flunitrazepam, was detected in a urine specimen collected when the complainant attended hospital approximately one day after consuming the adulterated drink.     

Acute concomitant injury and intoxication in complainants of recent sexual assault: A review

BackgroundSexual assault remains a highly prevalent crime worldwide and has the potential to cause a number of short and longer-term health sequelae. Complainants of recent sexual assault may undergo forensic and/or medical examinations for medical treatment or evidence collection, or both. However, the frequency and severity of acute health concerns requiring medical intervention in these patients at the time of examination is not well understood and has implications for their clinical care and safety.Aims & objectivesTo examine the frequency and severity of acute concomitant health concerns at the time of forensic examination following an allegation of recent sexual assault in post-pubertal (age >13 years) individuals, through a review of existing literature. Concomitant health concerns considered in this review include ano-genital and extra-genital injury, and acute substance intoxication.MethodsFour online databases (PubMed, Ovid Medline, CINAHL, Embase) were systematically searched with key terms regarding the topics of sexual assault, forensic examination, injury and intoxication. Articles were assessed for relevance based on inclusion and exclusion criteria.ResultsOf 562 titles, 53 full-text publications met the inclusion criteria. Frequency of ano-genital and extra-genital injury was highly variable across studies, and severity was inconsistently assessed and rarely reported. Medical treatment or transfer to acute care settings was more commonly required for extra-genital injuries. Non-fatal strangulation (NFS) was found to represent an increasingly frequent feature of sexual assault cases. NFS complainants often exhibit signs and symptoms of potentially lethal complications requiring urgent review in acute care settings. Substance use around the time of sexual assault was commonly reported by patients and detected in toxicological screens, and could have significant implications on patient and staff safety at the time of examination.ConclusionThe findings of this review highlight the clinical significance of acute concomitant health concerns following an allegation of recent sexual assault. Ano-genital and extra-genital injury, NFS and both voluntary and involuntary substance use may be more frequent and severe than previously understood. Further investigation into the assessment and management of these acute health needs is required to elucidate their clinical significance and inform evidence-based care for complainants of sexual assault.     

Vulnerable victims of sexual assault

Sexual assault is one of the heinous crimes of present day society. Although it has always been evident, in recent times there has been a steady increase in the rate of sexual assault cases. The aim of this study was to identify the groups most at risk. Therefore it includes only cases of sex offences and sex offences with kidnapping. Information was obtained by interviewing the victims and accompanying persons, and from records submitted by the investigating officers. Our study reveals sexual assault commonly occurs among the age group of 16-19 years (60.8%), mostly at night (53.23%), inside the house (87%) and usually by a close acquaintance (61%). The majority of the victims were unmarried (84.7%), lived in rural areas (65.2%), were unemployed (93.5%), of less educated or illiterate groups (88%) and found to be mentally fit (97%). The victims were mostly drawn from low socio-economic groups.     

A global epidemiological perspective on the toxicology of drug-facilitated sexual assault: A systematic review

PurposeA systematic review was undertaken to determine the current global prevalence of drug-facilitated sexual assault (DFSA) reported in adults in order to identify trends in the toxicology findings in DFSA around the world over the past 20 years.MethodsDatabases PubMed, PsycINFO and Scopus were systematically searched using the terms: “drug-facilitated sexual assault”, “chemical submission”, “date rape”, “rape drugs” and “drink-spiking” to identify relevant studies for inclusion in the review. This study focused on adult victims of suspected DFSA aged 16 years and above in which toxicology results were reported.ResultsThe majority of studies included were published in the United States, followed by the United Kingdom, with only a single study dedicated to this area in both Australia and Europe. Epidemiology, prevalence rates, and toxicology for DFSA appear broadly commensurate across different continents, although there are some differences in how “drug-facilitated sexual assault” is defined, as well as differences in the sensitivity of toxicological analyses. Nonetheless, alcohol is the most commonly detected substance and co-occurrence with other drugs is common. Aside from alcohol there was no other specific drug category associated with DFSA. Cannabinoids and benzodiazepines were frequently detected, but a lack of contextual information made it difficult to establish the extent that these substances contributed to suspected cases of DFSA.ConclusionsThis comprehensive review suggests that alcohol intoxication combined with voluntary drug consumption presents the greatest risk factor for DFSA, despite populist perceptions that covert drink-spiking is a common occurrence. There is a need to develop policies that encourage early responders to suspected DFSA (e.g., law enforcement agencies, medical staff, support agencies, etc), to collect detailed information about the individual's licit and illicit drug consumption history, in order to assist in providing appropriate and more thorough contextual information.     

Review of 212 individuals attending a city centre genitourinary medicine clinic following acute sexual assault

A retrospective case note review of 212 individuals (190 women) attending a city-centre Genitourinary Medicine clinic between 1/4/2002 and 31/3/2004 following an acute sexual assault. Direct referral by the Forensic Medical Examiner to the dedicated weekly clinic for victims of sexual assault facilitated the attendance of 55/113 attending the dedicated clinic. The 99 individuals who did not disclose a recent assault as the reason for attendance were seen at routine clinics. One third of individuals attending the dedicated clinic were less than 16 years old, reflecting the facilitated referral pathway. Those attending the dedicated clinic were more likely to be offered the extended service outlined in the departmental protocol. Twenty four sexually transmitted infections were detected in 23 (11%) individuals but 23/24 could have been acquired during other recent consensual sexual activity. Overall, the assailant was known to the victim in 53% cases, there was an allegation of violence associated with the assault in 20%, suspicion of a drug facilitated ('spiked drink') assault in 24% and admission of alcohol intoxication in 11% cases. The 22/212 (10%) who were male were more likely to present to a routine clinic.     

A retrospective observational study of genital findings in adult women presenting to a New Zealand Adult Sexual Abuse Assessment and Treatment Service following an allegation of recent sexual assault

ObjectiveThe aim of this study was to report on the prevalence of genital findings documented in women attending a forensic examination following an allegation of recent sexual assault. A secondary aim was to investigate for any associations between genital findings and variables related to population demographics and clinical factors.Study designA retrospective review of clinical records was undertaken for 593 women, aged between 17 and 45 years of age, who underwent a forensic examination within 72 h following an alleged sexual assault at the Pohutukawa clinic, adult Sexual Abuse Assessment and Treatment Service (SAATS) in Auckland, New Zealand over a four-year period. Statistical analysis to examine for any associations between any documented genital findings and subject variables was performed.ResultsThe key finding was that 66.4% (394/593) of the women had a normal genital examination. Of the 182 women with genital findings the presence of skin disruption and/or bruising was noted in 21.1% (125/593) and non-specific findings in 9.6% (57/593). 17 women were not included as the genital examination was incomplete. For 9.5% (56/593) of women the presence of abnormal genital skin was documented. From the adjusted odds ratios obtained by multivariate analysis there was a statistically significant association between the presence of genital findings and abnormal skin condition (OR 3.13, p = 0.0004).ConclusionThe study demonstrated that the majority of women seen within 72 h of an alleged sexual assault had a normal genital examination. Given the strength of the association between the presence of genital findings and skin condition, we recommend that documentation of the genital skin condition should become a routine part of a forensic examination following sexual assault. This is particularly important if genital findings are present, in order to present the full complexity of clinical examination findings to the court and provide an expert opinion regarding the limitations of attributing causation.     

The optimal timing of forensic evidence collection following paediatric sexual assault

BackgroundForensic evidence collection following sexual assault has an important medico-legal role. Despite the advent of DNA profiling, research into the optimisation of forensic biological specimen collection is limited. This has led to inconsistent and variable guidelines for forensic evidence collection. The guidelines in this jurisdiction (Victoria, Australia) recommends that specimens be collected up to 7 days following sexual assault in some circumstances. The aims of this study were to determine the optimal times post sexual assault for the collection of forensic biological evidence in paediatric cases (aged 0–17 years).MethodsA retrospective review of paediatric sexual assault cases seen by the Victorian Forensic Paediatric Medical Service (VFPMS) between 1 January 2009, and 1 May 2016, was undertaken. Specimen site and collection times post assault were collated from VFPMS medico-legal reports and compared with the forensic evidence analysis results reported by the Victoria Police, Forensic Services Department. In addition, a survey of recommended forensic specimen collection times post assault in the different Australian jurisdictions was undertaken for comparison.ResultsWithin the 6 year 5 month period studied there were 122 cases consisting of 562 different forensic specimens that were collected and analysed. 62 (51%) of cases produced one or more positive forensic result and, of the 562 specimens collected, 153 (27%) were positive for one or more of foreign DNA, spermatozoa, semen or saliva. Foreign DNA was more likely to be found if forensic specimens were collected during the first 24 h after the assault as compared with those collected at 25–48 h, (p < 0.005). Similarly, spermatozoa were identified more frequently on swabs collected at 0–24 h compared to 25–48 h (p < 0.002). Foreign DNA was not identified beyond 48 h post assault and spermatozoa were not identified beyond 36 h. Saliva and semen were not identified beyond 24 h. The youngest victims with positive forensic evidence were 2–3 years old. The survey of current forensic specimen collection practice in Australia shows that the guidelines for timing of forensic evidence collection in child sexual assault cases is highly variable between jurisdictions.ConclusionsOur results highlight the importance of collecting forensic specimens as a matter of urgency, regardless of age, within the first 48 h post assault. Although there is need for further research, the findings indicate a need for the re-evaluation of current guidelines for specimen collection in paediatric sexual assault cases.     

Injuries and allegations of oral rape: A retrospective review of patients presenting to a London sexual assault referral centre

A retrospective review was carried out of patients seen at the Haven sexual assault referral centre in South East London between January 2009 and September 2010 to determine the frequency and nature of oral injuries found in people reporting oral rape. Ninety five eligible patients were identified and relevant information was extracted from standardised Haven forms completed during forensic medical examination. The main outcome measures were prevalence, type and location of oral injury. Eighteen (19%) were found to have sustained an oral injury. The most common injury was abrasions, followed by bruising and petechiae. The lips were the most common site of injury followed by the soft palate and the inside of the cheeks. It was concluded that injuries in the mouth were not common after an allegation of oral rape. Injuries were minor and did not require treatment.     

Comparative study of spermatozoa detection using the genital swab versus bedside smear slide technique in sexual assault patients

BackgroundSpecimen collection from sexual assault victims is an essential part of practice in forensic medicine. Semen analysis is a forensic test used to confirm sexual contact. Two methods of specimen collection were compared in this study: the genital swab and bedside slide smear.Materials and methodsA retrospective chart review was performed in the Division of Clinical Forensic Medicine, Siriraj Hospital, Thailand. Data were collected on microscopic spermatozoa detection in the external and internal genitalia, the time interval from assault to visit, and the history of condom use and genital cleansing. McNemar's test was used for comparison between the genital swab and bedside slide smear techniques.ResultsIn total, 724 case files from 2009 to 2013 were reviewed. The genital swab technique yielded a higher detection rate than did the bedside slide smear technique in both the external genitalia (37.0% vs. 31.8%, respectively) and internal genitalia (40.8% vs. 34.1%, respectively). Collection of a genital swab only missed positive cases in 4%–6% of negative swabs. When considering both the external and internal genitalia, the genital swab still yielded a higher rate of positive results than did the slide smear (45.9% vs. 39.0%, respectively). Examination of the victim within the first 3 days produced the highest spermatozoa detection rate (46.3%).ConclusionsThe genital swab is the preferred specimen collection method for spermatozoa detection in adult sexual assault victims. However, collection of both a swab and slide specimen may be considered in some cases. Collection of specimens later than 3 days after the assault greatly decreases the rate of spermatozoa detection.     

Sexual assault practice: myths and mistakes

Stories about sexual activity abound and are often the source of considerable interest and speculation. These anecdotal accounts are rarely subjected to any serious scrutiny and yet may develop folklore proportions. It is concerning that many forensic practitioners are prepared to perpetuate similar myths behind a veneer of scientific practice. Practices such as impotence or virginity testing and the interpretation of penile measurements are lucrative endeavors that remain alive and well. Similarly, court evidence on topics such as the circumstances by which genital injuries were sustained, the relationship between pubertal staging and age or the interpretation of anal findings are often less than objective. These practices are unprofessional. Further, they have the potential to cause significant harm to many individuals and to undermine the standing of the criminal justice system.