~91~I G 1N,~,L C O N T l l I B U T I ~ N
:;exnal ns,,~ault
From the Departments of
Emergency Medicine and
Pathology,t Hennepin County
Medical Center;* and Hennepin
County Attorney's Office,¢
Minneapolis, Minnesota.
Received for publication
October 16, 1990. Revision
received July 8, 1991. Accepted
fi~r publication November 20,
1991.
Presented at the Society for
Academic Emergency Medicine
Annual Meeting in Portland,
Oregon, May 1986.
78/ 727
Finale Sexual Assault: Medical and Legal
Implications
Beth Rambow, MD* Study objective: Toassess the medical and legal effectiveness of
Cher Adkinson, MD, FACEP* this institution's existing adult female sexual assault protocol.
Thomas H Frost, JD, MPA*
Design: Retrospective review.
Garry F Peterson, JD, MD*
Setting: Urban public hospital.
Type of participants: One hundred eighty-two adult female sexual
assault victims undergoing evaluation within 36 hours of assault,
Measurements and main results: Each case was reviewed with
specific attention to associated injuries, sexually transmitted disease,
compliance with medical follow-up, pregnancy, and legal outcome. Half
of all cases had associated injuries. Nine percent of the women were
found to have genital trauma on pelvic examination, although only 29%
of these women had complaints of genital pain or bleeding. Ten per-
cent of all women had positive gonorrhea cultures at initial examina-
tion. Thirty percent of the women completed the follow-up protocol.
None of the women given postcoital estrogen therapy is known to have
become pregnant. Only 53 of the 182 cases had the potential for suc-
cessful prosecution with both a victim willi@ to cooperate in prosecu-
tion and an identified assailant. Thirty-four percent of these cases
resulted in a successful prosecution. Evidence of genital or nongenital
trauma was significantly associated with a successful legal outcome.
Conclusion: A physical and evidentiary examination, including pelvic
examination and assays for sperm and acid phosphatase, is warranted
in all cases of female sexual assault presenting within 36 hours of the
assault. Institutions dealing with victims from a transient, lower socio-
economic population should offer prophylactic treatment for sexually
transmitted disease and pregnancy rather than rely on compliance with
follow-up schedules.
[Rambow B, Adkinsen C, Frost TH, Peterson GF: Female sexual assault:
Medical and legal implications. Ann EmergMedJune 1992;21:727-731.]
ANNALS OF EMERGENCY MEDICINE 21:6 JUNE 1992
SEXUAL ASSAULT
Rambowetal
INTRODUCTION
The r e p o r t e d incidence of forcible rape has shown a steady
increase in the United States throughout the last decade. 1
Therefore, the management of the sexual assault victim con-
tinues to be an important and necessary aspect of emergency
department care. The sexual assault protocol at Hennepin
County Medical Center (Figure) was designed to assess and
treat injuries, protect the victim exposed to venereal disease,
prevent unwanted pregnancy, collect evidence to maximize
the successful prosecution of the assailant, and provide
psychological support for the victim. The procedures neces-
sary to meet these objectives are extensive, costly, and time
consuming. The initial l a b o r a t o r y examination alone costs
approximately $130 p e r patient. Total professional time for
the initial visit averages 4.33 hours, including 20 minutes
of physician time, two hours of ED nursing time, and two
hours of nurse-counselor time. In addition, the procedures
themselves may be distressing to the recent victim of sexual
assault. Finally, r e p o r t e d conviction rates for sexual assault
range from 8% to 20%. 2 s F o r these reasons, we undertook
a retrospective review to determine the medical and legal
usefulness of our protocol for sexual assault victims.
Figure.
Hennipen County Medical Center AduhFemale Sexual Assault Examination
Protocol*
Nursing interview: Assault history
Medical and gynecologic history
Physical examination: General physical including oral, pelvic, and rectal
examination when involved; photographs of injuries
LaboratoryF Swabs of all involved orifices (vaginal, oral, and/or rectal)
for gonorrhea, acid phosphatase, fixed smear (Pap), and
saline suspension for sperm, sperm type; VDRL, blood
type, and alcohol/drug screen when indicated
Urine pregnancy test
Pubic hair combings, fingernail scrapings
Saliva for secretot status
Treatment: Injuries
Pregnancy prevention (two Ovral®tablets orally, repeat
in 12 hours)
Counseling through Sexual Assault Resource Service
(SARS)
Follow-up: First visit (three to five days after assault): Treat positive
initial gonorrhea, cultures, repeat gonorrhea cultures,
counseling
Second visit (six weeks after assault): Repeat VDRL,
reassess pregnancy status, counseling, and continued
counseling by SARS as needed
* This protocol was used for victims presenting within 36 hours of the assault.
Changes made in the protocol on the basis of this study's findings are not
reflected in this figure.
t Hennipen County Medical Center laboratory performed analysis of cultures, VDRL,
acid phophatase, sperm motility and fixed smear, blood alcohol, and pregnancy
testing. Other samples were sent to the state crime laboratory.
JUNE 1992 21:6 ANNALS OF EMERGENCY MEDICINE
MATERIALS AND METHODS
One h u n d r e d ninety-one adult (more than age 16 years old)
female sexual assault victims were evaluated and treated at
Hennepin County Medical Center in 1983. Our study popu-
lation consisted of the 182 patients who agreed to have a sex-
ual assault evidentiary examination performed. Medical
examination, evidentiary examination, and treatment were
provided at no cost to the patient if the patient agreed to
have the evideutiary examination and to release the r e p o r t
and pertinent medical records to law enforcement. Data
were gathered by review of Hennepin County Medical Center
medical records, police reports, and legal files from the
Hennepin County Attorney's office. Attention was directed
toward associated injuries, evidence of male secretions
(sperm and acid phosphatase), venereal disease, pregnancy,
and legal outcome.
RESULTS
Ninety-five percent of the women who presented for evalua-
tion after a sexual assault agreed to the complete examina-
tion. More than half were examined within four hours of the
assault. Elapsed time between assault and examination is
detailed (Table 1).
Half of all the women suffered some type of injury as a
result of the assault. The vast majority of injuries were
minor, including abrasions, contusions, and minor lacera-
tions. F o u r women (2%) suffered a severe injury requiring
surgery and hospitalization. Vaginal or perineal injuries,
including small lacerations, contusions, and abrasions, were
sustained by 10% of the women. One-third of these pelvic
injuries were asymptomatic on presentation; none required
treatment.
Genital contact was made between the assailant and victim
in 177 cases, and in these, a p p r o p r i a t e testing was done for
syphilis and gonorrhea. Eighteen women (10%) had a posi-
tive initial culture for gonorrhea consistent with either a
large inoculum from the assault or a pre-existing infection.
One h u n d r e d one women r e t u r n e d as instructed for three-to
five-day follow-up. One had converted to a positive culture
for gonorrhea, suggesting infection acquired at the time of
the assault or an initial false-negative culture. Hence, posi-
tive gonococcal cultures were common in these assault vic-
tims, but difficult to interpret.
The fluorescent treponemal antibody absorption test was
positive on initial screening in one of the 177 women tested,
indicating pre-existing syphilis. Two of the 55 women (4%)
Table 1.
Elapsed time between assault and evaluation
Time Elapsed (hr) No. of Patients %
<4 101 55
4-8 33 18
8-12 20 11
12-24 20 11
> 24 8 4
728/ ?9
SEXUAL ASSAULT

Rrtrnbou' et al

who returned as instructed for follow-up at six weeks had
converted to a positive fluorescent treponemal antibody
absorption test, suggesting infection acquired at the time of
the assault.
A woman was considered at risk for pregnancy if she was
of childbearing age with regular menses, in midcycle, and
using inadequate birth control and there was a history of
penile-vaginal contact between the assailant and victim dur-
ing the assault. Eighty-one women fit this description, and
52 (61%) received a prescription for postcoital estrogens.*
The remaining 29 women either refused estrogen therapy, or
the physician failed to offer it. Thirty-two (40%) of the
women at risk for pregnancy had adequate follow-up at six
weeks to determine pregnancy status. Two of these women
became pregnant; neither had received estrogens.
Swabs were taken from all involved orifices. These vaginal,
oral, and/or rectal swabs were analyzed for the presence of
acid phosphatase and sperm in 172 women. One h u n d r e d
twenty-seven victims (74%) had evidence of male secretions;
specifically, 19 (11%) had elevated acid phosphatase only, 17
(10%) had sperm on microscopic examination only, and 91
(53%) had both. Table 1 lists the results according to the
amount of time elapsed between the assault and the collec-
tion of the specimens.
Table 2 depicts the steps involved in the legal process and
the n u m b e r of cases reaching each step. The majority of cases
were not charged. For those cases not charged, the reasons
included the victim being uncooperative or declining to press
charges (43%), an assailant could not be identified (33%),
there was lack of corroborating evidence or there was indeter-
minate consent for sexual activity (22%), or the case was
declared unfounded (2%). One case initially charged was later
dismissed when evidence gathered in the ED cleared the
defendant. Specifically, this involved a mismatch between his
blood group status and that of vaginal samples taken from the
victim. No case was dismissed because of a technical problem
with the collection of evidence in the ED or because of a break
in the chain of evidence.
*Ovral (50 g ethinyl estradiol and 0.5 mg norgestrel) two tablets taken orally preferably
within 12 to 24 hours and no later than 72 hours after intercourse, followed by a repeat
dose of two tablets 12 hours after the first dose. 6
The majority of cases were not charged because the victim
declined to press charges or an assailant could not be identi-
fied. Only 53 of the 182 cases had the potential for prosecu-
t i o n - b o t h an identified assailant and a victim willing to
press charges.
Table 3 looks specifically at these 53 cases and compares
the evidence available with the legal outcome. When one
looks at the presence of trauma and legal outcome, X2
analysis confirms that the evidence of trauma is significantly
associated with a successful prosecution (X2 = 7.85 with one
degree of freedom; P < .01). The injuries associated with
conviction were muhiple contusions and abrasions, h u m a n
bites, lacerations of the perineum, lacerations/puncture
wounds to the extremities, b u r n s , and depressed skull frac-
ture with severe head injury. Z2 analysis revealed that the
presence of sperm or acid phosphatase (indicating ejacula-
tion by the assailant), although tending to favor successful
prosecution, was not a statistically significant factor
(Z2 = .08 with one degree of freedom). The conviction rate
in this modified group was 34%.
DlSCUSSl0N
Sexual assault is a violent crime with 40% of all cases involv-
ing the use of a gun, knife, or b l u n t object a s a weapon. 7 Our
report of 50% associated injuries falls in the upper range
reported by other studies (11% to 5 8 % ) . 2-4,7-9 When one looks
specifically at the percent of victims who have associated
vaginal or perineal injuries, the reported range is much
smaller (5.2% to 19%).3,4, l°
Because only five of the 17 women who suffered vaginal
or perineal injuries reported associated pain, discomfort, or
bleeding, some of these injuries would have been missed if a
complete examination had not been done. This is relevant
because evidence of trauma was significantly associated with
successful prosecution. In addition, Minnesota, like a num-
ber of states, has statutes that categorize sexual assault into
four degrees On the basis of evidence of sexual penetration
and level of physical violence. J0 Therefore, evidence of vio-
lence potentially can influence the degree of sexual assault
charged.
Assays for the presence of sperm and/or acid phosphatase
are an integral part of the evidentiary examination.

Table 2. Table 3.
Comparison of the presence of male secretions according to time interval from Comparison of evidence available and legal outcome*
assault
Trauma Reported No Trauma Reported
Time Interval Between Assault Semen No Semen Semen No Semen
and Specimen Collection (hr)
0-4 4-8 8-12 12-24 24-36 Successful prosecution 11 3 3 1
(101) (31) (18) (10) (4) Unsuccessful prosecution 8 5 18 4
Result No. (%) No. (%) No. (%) No. (%) No. (%) Total 19 8 21 5
% Successful prosecution 58 38 14 20
+ Acid phosphatase* (%) 73 (72) 15 (48) 12 (67) 8 (44) 2 (50)
*All cases with a cooperative victim and an identified assailant (53).
- Acid phosphatase* (%) 28 (28) 16 (52) 5 (28) 10 (56) 2 (50)
+ Sperm 70 (69) 16 (52) 10 (56) 10 (56) 2 (50) The four evidence conditions manifested significantly different prosecution success rates
- Sperm 31 (31) 15 (48) ,8 (44) 8 (44) 2 (50) (Z2 = 8.96 with 3 df; P < .05). The presence or absence of trauma appeared to be the meier predictor
* Acid phesphatase by thymophthalein rnonophosphate method was defined as positive if 8 IU er of significance (Z2 = 7.85 with 1 df; P < .01}.The presence of male secretions, although tending to
more, negative if less than 8 ]U. favor successful prosecution, failed to reach statistical significance (Z2 = .08 with 1 dr).

80/729 ANNALS 0F EMERGENCY MEDICINE 21:6 JUNE1992

SEXUAL ASSAULT
R a m b o w et al
Although in this study the presence of sperm or acid phos-
phatase was not statistically associated with successful prose-
cution, this evidence did clear one accused assailant and
hence contributed to a just legal disposition.
Historically, the follow-up of the sexual assault victim has
been a significant problem, with various studies reporting
follow-up rates of 6% to 60%. 3,4,8A° Our overall follow-up
rate of 63% falls in the upper range but remains far below
optimal. Possible explanations for the high failure rate for
follow-up examinations include denial or suppression of the
assault by the victim, poor understanding by the victim con-
cerning the need for follow-up examinations, and displace-
ment of the anger that the victim feels toward the assailant
onto the medical system.
In addition, certain characteristics (ie, psychological prob-
lems, transient living, and lower socioeconomic class) appear
to make some women more vulnerable to sexual assault.
These same characteristics make victims less accessible to
traditional follow-up. 12 Compliance with follow-up in our
patient population was adequate for the detection of gonor-
rhea in only 63% of victims and syphilis in 33%. This was
identified as a major area of concern because a significant
n u m b e r of victims with adequate follow-up were shown to
have a sexually transmitted disease potentially acquired at
the time of assault, and others without adequate follow-up
may have contracted disease as well.
These findings would confirm the recommendation in many
articles for prophylactic treatment of sexually transmitted
diseases in the rape victim.2-s,9J° Prophylactic treatment
would prevent the development of disease in patients who do
not follow up in three to five days. Prophylactic treatment
would also eliminate the inconvenience of repeat examina-
tion in three to five days, as well as the expense of initial cul-
tures and follow-up examination and cultures. Furthermore,
because many women are physically and emotionally distressed
by the assault, it would benefit them psychologically to know
that they r u n no risk of acquiring gonorrhea, chlamydia, or
syphilis from the assailant.
The reasoning behind this institution's protocol of doing
initial and follow-up cultures rather than treating prophy-
lactically was to gather corroborative evidence to support
the claim of rape by demonstrating that women contracted
disease from their assailants. However, a negative initial cul-
ture coupled with a positive follow-up test for venereal dis-
ease was open to several interpretations, and in this study
had no bearing on the legal outcome of the case. On the basis
of this information, this institution's protocol for adult rape
victims has since been revised to provide prophylactic treat-
ment for gonorrhea, syphilis, and chlamydia.*
*Cefuroxime 1.0 g 6rally plus probenecid 1.O g orally at the time of evaluation, followed
by doxycycline 100 mg orally twice daily for seven days; alternative regimens for
allergic and pregnant patients as recommended in United States Public Health Service
Guidelines) 3
JUNE 1992 21:6 ANNALS OF EMERGENCY MEDICINE
Pregnancy is a highly undesirable result of rape. In this
study, follow-up was inadequate for early detection of preg-
nancy in 40% of cases. Because postcoital estrogen therapy
is an effective means of pregnancy prevention, 6 the results of
this study support offering postc0ital estrogen to the assault
victim at risk for pregnancy.
With respect to legal issues, the protocol was effective inas-
much as there was no instance of a break in the chain of evi-
dence, and no case was dismissed because of a failure to col-
lect evidence. The overall conviction rate was 10%; the
conviction rate for those cases with a cooperative victim and
identified assailant was 34%. This compares with conviction
rates in other studies of 8% to 20% .2-5
CONCLUSION
The management of the sexual assault victim can be a diffi-
cult and time-consuming process for the ED staff. It may be
frustrating to collect the necessary evidence only to have the
victim decline to press charges. On the other hand, if the
case results in conviction or if an innocent defendant is
cleared, the time spent in the ED is easily justified.
At the time of the initial examination, the victim's decision
and the outcome of the case cannot be predicted. Defenses
such as fabrication, consent, or mistaken identity may not
be proffered for weeks or months. The physician seeing a
sexual assault victim has only minutes in which to make an
examination that will enable him or her to answer all of the
scientific questions that may arise in the case.
On the basis of this review, the authors conclude that a
complete physical and evidentiary examination, including
pelvic examination and assays for male secretions, is war-
ranted in all cases of female sexual assault that present to
the ED within 36 hours of the assault. Furthermore, institu-
tions dealing with victims from a transient, lower socioeco-
nomic population should implement prophylactic treatment
for sexually transmitted disease and pregnancy rather than
rely on compliance with follow-up schedules.
Even institutions able to ensure follow-up for victims of
sexual assault should offer prophylactic treatment for sexu-
ally transmitted diseases to limit cost, inconvenience, and
victim distress. F u r t h e r research is needed to determine if
prophylaxis should be given for HIV, hepatitis B, and herpes
infections as well.
REFERENCES
1. US Bureau of the Census: StatisticalAbstractofthe UniteflStates in 1990,ed 110.
Washington, DC, USBC, 1990.
2. Talbert S, White SD, et al: Improving emergency department care of the sexual
assault victim. Ann Emerg Med 1980;9:293-297.
3. Soules MR, Stewart SK, Brown KM, et al: The spectrum of alleged rape. J
Reproductive Med 1978;20:33-39.
4. Tintinalli JE, Hoelzer M: Clinical findings and legal resolution in sexual assault. Ann
Emerg Med 1985;14:447-453.
7 30 / 8 1
SEXUAL ASSAULT
R a i n b o w et al

5. Schelble BT, Bradford JC: An 18-month evaluation of the Akron General Medical Address for reprints: Cher Adkinson, MD, FACEP, Department of Emergency
Center assault/rape protocol. Ann Emerg Med 1982;11:9-17.
Medicine, Hennepin County Medical Center, 701 Park Avenue South, Minneapolis,
6. Ovral as a "morning-after" contraceptive. Med Letter 1989;31:93-94.
Minnesota 55415.
7. Tipple AL, Julian TM: Sexual assault: The problem and its management. Minn Med
1984;433-436.
8. Haymen CR, Lanza C: Sexual assault on women and girls. Am J ObstetGynecol
1973;109:480-486.
9. Evrald JR, Gold EM: Epidemiology and management of sexual assault victims. Obstet
Gynecol 1979;53:381-387.
10. Massey JB, Garcia CR, Emich JP Jr, et al: Management of sexually assaulted
females. Obstet Gynecol l971;38:29-36.
11. Binder RL: Difficulties in follow-up of rape victims. Am J Psychother 1981;35:534-541.

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