Sexual Assault Victim Examination



Sexual assault is defined as a threat of or actual sexual contact with or without penetration without the willing consent of the victim, whether by threat of physical force, psychological pressure, or facilitation by the use of alcohol or drugs [1]. Rape is considered an act requiring forced penetration of the mouth, genitals, or anus by the offender where the force is either physical or psychological [2]. One in six American women is a victim of sexual assault. In 2004–2005, there were an average of 200,780 victims of rape, attempted rape, or sexual assault. Of these women, 44% were under the age of 18 [3]. The rate of rape and sexual assault has fallen by more than half, although a large percentage of cases still go unreported [4].


Last Menstrual Period Forced Penetration Helpful Hint Sexual Assault Nurse Examiner Hospital Gown 
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Sexual assault is defined as a threat of or actual sexual contact with or without penetration without the willing consent of the victim, whether by threat of physical force, psychological pressure, or facilitation by the use of alcohol or drugs [1]. Rape is considered an act requiring forced penetration of the mouth, genitals, or anus by the offender where the force is either physical or psychological [2]. One in six American women is a victim of sexual assault. In 2004–2005, there were an average of 200,780 victims of rape, attempted rape, or sexual assault. Of these women, 44% were under the age of 18 [3]. The rate of rape and sexual assault has fallen by more than half, although a large percentage of cases still go unreported [4].

When a victim of rape presents to the Emergency Department or private office for examination, one of the most important issues is to take steps to preserve all forensic evidence to insure that there are few impediments to prosecution. It is important to be complete and thorough in the exam and evidence gathering, while at the same time being sensitive to the fact that the victim has likely already endured a lengthy process prior to arriving for her physical examination. To that end, the number of examiners and interviews should be kept to a minimum with as much history as possible being obtained from law enforcement personnel, social workers, and family members. This use of the team approach toward evaluation and treatment is effective in minimizing the trauma of the emergency department setting [5]. With that background, a more focused interview can be obtained from the victim using as many of the victim’s own words as possible in recording the history. The interview process need not be duplicated, except as it pertains to specific evidence that needs to be collected for a more in-depth, directed physical exam or specimen collection. Offering to have a support person present (who is not suspected of the abuse) may be reassuring to victims of all ages [6].

It is helpful to have a second professional (nurse, aide) assist during the exam and evidence collection, not only to serve as a witness, but also to provide materials and label evidence promptly as it is collected. This will lessen the possibility of lost specimens and speed up the process by allowing the examiner to continue wearing gloves during the entire examination without having to change them for record-keeping. Specially trained nurses in the Sexual Assault Nurse Examiner (SANE) program help coordinate all the team members and minimize further trauma to the victim [7].

Case Study

A 22-year-old woman was at a party with her friends where alcohol was being served. She does remember drinking two beers within a time span of 3 h but did not take any drugs. She recalls dancing with several young men, but she now has a headache, her clothing is disheveled, and she is experiencing vaginal spotting. She suspects that she may have been the victim of unwanted sexual advances, but her memory is fuzzy for the event. She is presently on oral contraceptives, and her last menstrual period was 1 week ago.

Indications (Algorithm 6-1)

Suspected rape


Unwilling or uncooperative patient


  • Speculum: disposable

  • Lubricant

  • Light source

  • Rape Kit: as determined by local law enforcement agencies. (This includes envelopes, swabs, and slides for evidence collection, as well as forms with routine questions and diagrams.)

  • GC/Chlamydia test kit with swabs, depending on local custom.

  • Venipuncture materials: needle, vacutainer collection tubes, alcohol prep, gloves, gauze

  • Urine collection container with cleansing wipes

  • Rapid pregnancy test kit

  • Pencil for labeling specimens on glass slides

  • Pen for recording findings and labeling envelopes

  • Nonsterile exam gloves

  • Clean sheet for patient to stand on while collecting clothing for evidence. Hospital gown for patient to wear during exam and clean sheet for cover-up.

  • Water for dampening swabs to collect evidence

  • Paper bags in various sizes to collect clothing

  • Extra clothing for victim, preferably “street clothes” as opposed to hospital gown

Optional Equipment

  • UV light (see Sect. “Tricks and Helpful Hints”)

  • Colposcope with video capabilities to record the evidence as collected

Procedure (Algorithm 6-1)

  1. 1.

    Consent must be obtained from the victim or a parent/legal guardian (in the case of a minor) in order to release the specimens to law enforcement authorities.

  2. 2.

    Medical history, noting:

    Any complaints of injuries related to the alleged sexual abuse. The rape kit forms are very thorough in assessing and recording the circumstances of the sexual assault and which body parts of the victim came in contact with which body parts of the perpetrator.

    The date and time of alcohol or drug intake, if applicable.

    Last menstrual period (LMP), prior pregnancies, sexual partners, birth control. Past medical history. List of current medications. Allergies.

  3. 3.

    Observe and record the general appearance and demeanor of the victim, noting any obvious injuries. Any potential life-threatening injuries should be attended to first.

  4. 4.

    Wearing nonsterile gloves lay out a clean white sheet on the floor.

  5. 5.

    Have the patient undress on the sheet, which will prevent any contamination of clothing and secure any fibers or evidence that may be on clothing, lodged in the patient’s hair, or under her fingernails.

  6. 6.

    Have the patient completely disrobe while standing on the sheet and package each piece of clothing individually in a paper bag, which should then be sealed. If the victim has showered and changed clothing after the sexual assault has occurred, this step may be unnecessary. Provide patient with a hospital/office gown and a sheet.

  7. 7.

    A complete physical exam should be performed with special attention directed to the oral cavity, skin around and near the breasts, and the perineal area (Fig. 6-4).

  8. 8.

    Using the rape kit as a guide, proceed from head to toe gathering specimens as appropriate and placing them in the appropriate envelopes (Fig. 6-1).

  9. 9.

    Thoroughly dry all specimens prior to packaging to avoid the destruction of samples by mold growth (Fig. 6-2).

  10. 10.

    Obtain cervical swabs to be sent to the local laboratory for gonorrhea and chlamydia by the preferred local detection method.

  11. 11.

    In order to minimize further trauma to the patient, specimens of the victim’s scalp hair and pubic hair (which must be plucked) can be obtained either at this step or at any follow up visit under less stressful circumstances.

  12. 12.

    Seal the rape kit with the special stickers provided and sign off each sticker with time and date and initials of the examiner. The kit must be handed directly to a law enforcement officer in order to preserve the chain of evidence (Fig. 6-4). Sign each page (usually 15–20 pages, not including duplicates) and hand the originals to the officer, keeping copies for the chart and sexual abuse management (SAM) clinic.

  13. 13.

    Blood and urine specimens should be labeled and delivered to the lab. The prosecutor will obtain these results later.

  14. 14.

    Perform serum toxicology screens – alcohol, drug screen if indicated – noting time of alcohol ingestion obtained in history, if known. These specimens are sent to the local hospital laboratory. Specimens may also be sent for Hepatitis B, Hepatitis C, and HIV.

  15. 15.

    Results of the rapid pregnancy test and/or quantitative βHCG results should be obtained and recorded if the patient is a female of childbearing age.

  16. 16.

    Offer pregnancy prophylaxis, if indicated.

  17. 17.

    Sexually transmitted disease prophylaxis should be provided empirically based on local and current guidelines.

  18. 18.

    Arrange a follow up appointment to review labs, discuss emotions concerning the assault. Local support groups are often invaluable for handling the emotional aftermath.

Fig. 6-1

Partial rape kit contents

Fig. 6-2

Additional rape kit contents

Fig. 6-3

Rape kit box with all necessary forms and packaging materials for samples collected. External portion of box with check-off list of sent contents

Fig. 6-4

Chain of custody sealed rape kit; front of rape kit box (State of New Jersey)

Algorithm 6-1

Decision tree for sexual assault victim

Tricks and Helpful Hints

  • UV light has been used in the past to highlight areas of semen on skin and in hair; however, studies have recently shown that this yields confusing results, as many common items (such as K-Y jelly and powder) will fluoresce. Local authorities may dictate whether this step is performed, but it is not recommended.

  • It is VERY IMPORTANT to check the date on the seal of the rape kit before proceeding to determine that it has not expired. Otherwise, all evidence collected may be considered invalid and the case may not be able to be prosecuted.

  • Many of the “date-rape” drugs do not have metabolites that can be detected on routine toxicology screens. However, some drugs may be possible to detect if special instructions are given to the laboratory. Check with local law enforcement as some specimens can be sent to the state lab for testing of metabolites. The length of time from drug ingestion to collection of the specimen also plays a role in the likelihood of detection [8].

  • It is the patient’s preference to decide on her own about pregnancy prophylaxis, even if that patient is a minor.

  • Special handling and special consent may be needed for HIV serology.

  • If the patient prefers, have a support person present during the exam.

  • When an assessment is made, it is important to note that although the physical exam may be normal, this does not exclude the possibility that a sexual assault did indeed occur, and this should be discussed with the patient and with the authorities.

  • In some areas of the country, clinicians use a colposcope to aid in recording details in the woman’s examination, including bruising or bleeding consistent with trauma.

Procedure Note Provider to Customize as Needed

The rape kit provides a very elaborate and thorough form for recording various aspects of the history and physical exam. An additional note for the hospital or office record may make a reference to these documents and should summarize the major findings.

For example:

CC: 22 yo female c/o alleged sexual assault 12 h prior to admission. Patient consumed one beer at 1:00 am. Patient has voided and brushed her teeth, but has not showered, douched, or defecated since the event. She changed her clothes prior to going to police station. No other injuries. LMP 9/13/07 G1P0010 sexually active, one partner, on oral contraceptives. No significant past medical history. No other meds, no known allergies.

PE: Small abrasion of left labia minora with no active bleeding; exam otherwise normal. (See rape kit sheets.)

A/P: Alleged sexual assault. STD and pregnancy prophylaxis offered. Hepatitis, HIV, GC/chlamydia pending. Patient to f/u with Sexual Abuse Management (SAM) Clinic.


CPT® Codes (Current Procedural Terminology, AMA, Chicago, IL)


Rape; descriptor code used in conjunction with codes describing trauma.


Observation following alleged rape or seduction. V codes are supplementary or secondary diagnosis codes to support other primary diagnosis and conditions.

Postprocedure Patient Instructions

Follow-up to be arranged with the local Sexual Abuse Management team or equivalent where counseling can be provided; follow up on infections and diseases can take place, and these can be treated if necessary. Appropriate follow up should also be made to manage any injuries that may have occurred during the sexual assault.

Case Study Outcome

The patient has been evaluated by the clinician in the emergency room for rape. She has elected to be treated for sexually transmitted infections. She decided to follow up with her primary care clinician and is planning on going to the next meeting of the support group for women who have been sexually abused.

Postprocedure Patient Handout

(Provider to customize as necessary.)

You have just been evaluated for sexual assault (rape). It is important to remember that what happened is not your fault. No one “deserves this” or was “asking for it.” Rape is a crime. You have a right to report this to the police, and you have the right to be treated fairly during the justice process.

Many people experience a widely varying set of emotions, including rage, depression, anxiety, and fear. This is normal. In addition, it is very common for loved ones to have similar reactions. It is important not to “take the law into your own hands,” as these actions will likely end in more hardship to you and to your loved ones. Allow the law to do its job. Law enforcers are specialists and are there to assist you in bringing the perpetrator to justice.

Some women prefer private counseling with a psychologist or mental health social worker. Many people find support groups quite helpful. These local support groups often have trained therapists and other women who have gone through similar circumstances. Talking with people who have also experienced rape often helps people understand their own feelings and emotions. There are also national groups to help support women through the crisis of rape:
  • National Coalition Against Sexual Assault: telephone: 1-717-728-9764.

  • Rape, Abuse and Incest National Network: telephone: 1-800-656-HOPE.

It is also important to follow up with the medical issues surrounding sexual assault. This can be done by a local Sexual Abuse Management team or at your primary care physician’s office.

If you are on birth control and are taking it regularly, the likelihood of pregnancy is low. If you wish to be treated for prevention of pregnancy, you may be given a series of pills to take. It is important to take them as directed. If you are concerned about the possibility of infection, you may be treated for gonorrhea, chlamydia, and syphilis. If you are concerned about getting HIV, understand the risk of this is less than 1%. However, if you elect to be treated, be sure to take the medication as directed.


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Additional Resources Books

  1. Crowley SR. Sexual assault: the medical-legal examination. Stamford (CT): Appleton & Lange, 1999.Google Scholar
  2. Girardin BW, Faugno DK, Seneski PC, Slaughter L, Whelan M. Color atlas of sexual assault. St. Louis, MO: Mosby, 1997.Google Scholar
  3. Lavelle J. Forensic evidence collection. In Giardino AP, Alexander R (eds): Child maltreatment: a clinical guide and reference, 3rd ed. St. Louis, MO: G.W. Medical Publishing, 2005.Google Scholar
  4. Christian CW, Giardino AP. Forensic evidence collection. In Finkel MA, Giardino AP (eds) Medical evaluation of child sexual abuse: a practical guide, 2nd ed. Thousand Oaks, CA: Sage, 2002.Google Scholar
  5. Sexual Assault Nurse Examiner (SANE): Development and Operation Guide, US Department of Justice, Office of Justice Programs, Office for Victims of Crimes, Washington, DC, 1999.Google Scholar


  1. .
    Laraque D, DeMattia A, Low C. Forensic Child Abuse Evaluation: A Review. Mt Sinai J Med 2006;73(8):1138–1147.PubMedGoogle Scholar

Web Sites

  1. Sexual Assault Resource Service (SARS):
  2. Sexual Assault Nurse Examiner (SANE) Programs:

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Department of Pediatrics, Division of Pediatric Emergency MedicineUniversity of Medicine and Dentistry of New JerseyNewarkUSA
  2. 2.The Bristol-Myers Squibb Children’s Hospital at Robert Wood Johnson University HospitalNew BrunswickUSA

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