Health Professionals about to see a patient following a sexual assault

For advice, call SARC on (08) 6458 1828

or

via King Edward Hospital switchboard (08) 6458 2222 any time


Role of SARC Clinical Forensic Medicine Doctors

Metropolitan

  • SARC doctors see people aged 13 years and over for medical and/or forensic assessment if the alleged assault occurred less than 2 weeks ago.
  • SARC can see people whether or not they intend reporting to the police. 

SARC doctors may refer a patient to ED if SARC suspects a serious injury, acute psychiatric illness, or intoxication which cannot be safely managed at SARC.

Regional and remote, WACHS

  • SARC doctors are on-call 24 hours a day for the whole of Western Australia to provide telephone advice to health professionals who are seeing patients alleging a recent sexual assault. This service is available to staff in regional, rural and remote areas, including WACHS hospitals, regional clinics and mine sites. General Practitioners are also encouraged to contact SARC when seeing patients reporting sexual assault.
SARC doctors provide specific specialist advice to health professional who have been requested to perform forensic specimen collection by the police.
Patient Checklists

See below for recommended triage/checklist forms for patients presenting to EDs alleging recent sexual assault (Note: these forms are double-sided)

How to refer a patient to SARC

The SARC Duty Doctor can be directly contacted at SARC (08) 6458 1828 or via KEMH switchboard (08) 6458 2222.

To assist the SARC doctor to determine what support SARC will provide, the following types of questions will be asked:

  • what type of assault has been alleged?;
  • what medical examination and/or treatment has the patient received?;
  • does the patient have the capacity to consent to a forensic examination (if required)?; and
  • what location is most appropriate to see the patient? (SARC premises are separate from the main hospital). 

The patient will also be required to speak directly to a SARC counsellor for triage purposes. SARC is a voluntary service and the patient must understand and consent to being seen by SARC workers. 

Once the SARC team have decided the best time and place to see the patient, both the patient and referring doctor will be informed. The SARC doctor will ask that any hospital notes and/or referral letter be either faxed to (08) 9381 5426 or emailed to: WNHS.SarcDuty@health.wa.gov.au.

Patient notes can be emailed directly to the SARC medical team on WNHS.WHGMH.sarcdutymedical@health.wa.gov.au.

Please remember that any medical concerns always take precedence over forensic issues.

Important information to consider

Serious injury

If a patient has serious injuries, he/she should be triaged and treated medically as per the protocol of your department. Medical concerns take priority over forensic issues.

  • Assess and treat intoxication, poisoning, injuries and psychiatric emergencies as you would any other patient. 
  • Assess injuries specific to penetration, such as vaginal or anal pain or bleeding, and abdominal pain. 
  • Ask about non-fatal strangulation and assess for complications. Consider appropriate imaging if required (CT angiogram).
  • If serious injuries are suspected, consider the need for surgical or gynaecological referral.
  • Where the patient requires surgical or gynaecological referrals and any internal examinations or procedures such as in-dwelling catheter insertion, please include the SARC doctor in liaison so that arrangements for an appropriate forensic examination can be made. 
  • If a foreign body is removed from the patient, please document this removal and package up the foreign body in an appropriate forensic specimen collection bag.

Time between the assault and the examination 

The SARC medical team will see patients up to 2 weeks after a sexual assault. 

Time interval is important with regards to the likelihood of obtaining meaningful forensic specimens and documenting injuries. Below is a guideline only.

  • <5-7 days for penile-vaginal penetrations
  • <2 days for penile-anal penetrations
  • <1 day for penile-oral penetrations and digital-vaginal penetrations
  • Object penetrations are generally less.

Medically STI and blood-borne virus screening can be done at any time although the time interval is important with respect to emergency contraception and HIV prophylaxis.

If the assault was more than 2 weeks ago and medical issues have already been addressed, offer the patient the SARC counselling number: (08) 6458 1828 (08:30 – 23:00hrs). 

Nature of assault/penetration

Specifically ask about vaginal, oral and anal penetration(s) and if so by what (penis, finger(s), object), condom use, ejaculation and if any implements were used.

Prompt questions to aid the examination are on the SARC Emergency Care Checklist. 

Always ask about sexual assault in patients presenting after family and domestic violence physical assault.

Additional information

Other important information may include:

  • If the patient has showered or changed clothes
  • If the patient has had sex afterwards
  • If the patient has involved the police
Medical issues after an alleged sexual assault

This information is relevant to GPs and WACHS workers; and if the patient is not coming directly to SARC.

Emergency contraception 

  • Levonorgestrel (Postinor) 1.5mg as a single dose. This should ideally be given within 72 hours of the sexual assault but can be given up to 5 days later. 
  • Ulipristal (Ella One) 30mg. Up to 5 days post sexual assault, more effective than levonorgestrel after 72 hours and immediately preceding ovulation (if known).

STI and blood-borne virus investigations and prophylaxis

Discuss with the SARC duty doctor first, especially if the patient is considering a forensic examination. Consider the need for an external ano-genital examination +/- vaginal speculum examination (see below).

Investigations

  • First void urine: Chlamydia, Gonorrhoea and Trichomonas PCR
  • SOLVS: as above
  • Throat and anal swabs (if assaulted): Chlamydia and Gonorrhoea PCR
  • SOLVS or HVS: MC&S
  • Blood: Hep B, C, HIV and syphilis serology

Prophylaxis (consider)

  • Azithromycin 1 gram orally stat
  • Ceftriaxone 500mg IM or IV stat, if high risk gonorrhoea or if the patient is unlikely to attend follow-up. 
  • Hepatitis B vaccination (if patient has never been vaccinated or requires a booster vaccination)
  • Hepatitis B immunoglobulin, if not know to be immune and high risk assailant
  • HIV anti-retroviral therapy. Discuss with Infectious Diseases/SARC Doctor
    • Tenofovir 300mg/ Emtricitabine 200mg (Truvada) one tablet daily for 28 days, if considered a high risk assault. Truvada starter pack is available in ED containing a 7-day supply.
    • The patient will then need follow-up at a sexual health clinic or infectious diseases clinic or hospital for follow-up of HIV anti-retroviral treatment.
  • Safe sex – advise the patient to practice safe sex and use condoms if assault was not by a usual sexual partner.
Medical Follow-up

At 1 month

  • Pregnancy test (females only)
  • Repeat STI screen
  • Administer second Hep B vaccination if not immune
  • Can check serology especially if the patient is very anxious
  • Ask about psychological symptoms and psycho-social well-being
  • Assess if counselling referral required.

At 3 months

  • Repeat Hep B, C, HIV and syphilis serology
  • Administer 3rd Hep B vaccination if required
  • Check psycho-social well-being and refer if patient agrees
Forensic Kits
Early Evidence Kits (EEKs) enable patients to collect their own forensic samples and have been developed to allow for patient comfort without loss of forensic evidence. The use of a self-collected EEK allows the patient to pass urine, open their bowels and/or have something to eat, prior to a full forensic examination.

The Kits are easy to use and include instructions for use. They are acceptable to both patients and the justice system.

Male and Female Forensic Sexual Assault Examination Kits contain the documentation and items required for medical staff to conduct a full forensic examination on both male and female patients. 

The above Kits must be used as they have been packed to ensure that the contents are sterile and DNA-free. All Kits include tamper-evident bags to maintain chain of evidence.

Your department may already have a supply of Kits. If so, please follow the instructions inside the Kit. Document the time and date the Kit was collected in your medical records.

Patient consent is essential BEFORE a Kit is handed-over to the police. Please document in the patient notes and on the tamper-evident bag the time and date the Kit was handed over to the police.

After collection, best practice recommends that the Kits are stored in a refrigerator (if possible).

Only EEKs can be provided to patients for transporting to the police. If the tamper-evident bag is given to the patient, please document this in the notes, including the time and date this was done.

Other Sexual Assault Examination Kits must not be given to patients and must be provided by a medical professional to a police officer.

Forensic examination after an alleged sexual assault

Consent for a forensic examination

As a forensic examination has no therapeutic benefit, the patient must have understanding and the capacity to give informed consent to each component of the examination.

To consent to a forensic examination, a patient cannot be:

  • Intoxicated (alcohol and/or drugs),
  • Severely intellectually disabled,
  • <18 years of age (need responsible person).

The consent situation may vary if the police are involved. If the police are involved, they will provide a completed Criminal Investigation Act “Involved Person (Victim/Witness) Forensic Procedure Consent Form” which may help determine appropriate people to consent on behalf of or in addition to the patient.

Consent issues can be complex and we advise contacting a SARC doctor for clarification.

General forensic physical examination

Informed written consent is required for a forensic examination (see forensic specimen collection section below) and is advisable even if the patient is not involving the police.

Regional and rural services including WACHS are more likely to be requested to complete a forensic examination than services in the metropolitan area. Consult with the duty SARC doctor before commencing an examination.

Always use a SARC Male/Female Sexual Assault Examination Kit, which includes documentation notes and information on maintaining the chain of evidence for specimens. The examination kits are designed to prevent cross-contamination of DNA and have up to date.

Conduct the examination in a quiet, confidential space and allow time for the patient to consider all options throughout. Ensure that the patient is warm and covered up as much as possible.

If patient has removed clothing in order to be examined please consider collection of this as evidence to be given to patient or police. See collection of clothing section.

Examine one area at a time.

Record ALL injuries (if there are many, consider grouping) on the body diagram pages of the SARC Forensic Examination Record. Consider the use of the hospital photographer if available to aid documentation (if patient gives consent). If this service is not available suggest to the police that they arrange a police photographer.

Injuries which are not medically significant may be forensically relevant.

Injury types are:

Blunt force: bruises, abrasions (scratches and grazes) and lacerations (splits or tears, 

Sharp force: slash wounds (superficial sharp force injury) and stab wounds, ie from a knife or glass.

Other: bullets wounds, burns.

Remember a cut with a knife or glass is NOT a laceration!!!

Ano-genital examination

If the patient is coming to SARC and it is clinically relevant, perform an external ano-genital examination only.

Document any injuries noted.

Injuries following an alleged sexual assault are often small (<0.5cm) and are generally not medical significant and rarely need medical treatment. 

If in WACHS or the patient has declined SARC services and a speculum examination is required for medical and/or forensic specimen collection, use a small sterile speculum and either sterile water for lubrication (forensic specimen collection) or a minimum amount of medical lubricant.

Proctoscopic examination is rarely clinically indicated.

If speculum or proctoscope examination is required, consider discussing with the duty SARC doctor beforehand.

Forensic biology specimen collection 

This is collected to look for the alleged assailant’s DNA which may be found in semen, saliva, blood and exfoliated skin cells.

Specimens depend on nature and timing of assault. Each case is unique.

DNA contamination minimisation procedures should be performed prior to forensic biology specimen collection 

The following are suggestions only. 

Oral penetration:

  • Oral rinse, peri-oral swabs and smear

Vaginal penetration:

  • Labial, perineum, LVS, HVS, ECS vaginal speculum swabs and smears

Anal penetration:

  • Perianal, anal, rectal, proctoscope swabs and smears

Skin swabs – sperm, saliva, blood or contact

Fingernails scrapings 

Pads, tampons, foreign bodies

Document on the Forensic Biology Specimen page

  • Forensic Toxicology specimen collection

This is collected when a patient suspects that they may have been affected by alcohol or drugs at the time to such an extent that would negate their ability to consent to sex.

This could be self-administered for recreational purposes or covertly as in drug-facilitated sexual assault. 

Specimens collected:

  • Urine in a yellow-top pot,
  • Urine put into a EDTA (grey) blood tube and 
  • Venous blood.

Urine in a blood tube prevents bacterial activity which might either increase or decrease the alcohol content of a sample.

It is important to advise the patient that these specimens may detect any and all drugs (prescribed and recreational) used in up to a 2 weeks period (depending on the drug). The police generally will turn a blind eye to recreational drug use provided that the patient has declared this to them.

To help the laboratory with the calculations, it is also important to record the:

  • Exact time that each specimen was collected
  • The weight of the patient
  • The height of the patient
  • Any prescribed or other drugs the patients admits to consuming,
  • The approximate amount of alcohol the patient admits to consuming, and
  • The time of the last drink or drug use.
Document on the Forensic Toxicology Specimen page

For further advice as to when and how to collect forensic toxicological specimens, please contact the SARC duty doctor.

Collection of clothing

When considering which clothing to collect, remember that the patient may not get the item back and if so, it may have had a piece cut out for forensic analysis.

Only collect what is forensically relevant and what the patient is prepared to relinquish.

Give the patient the same number of paper bags as items of clothing to collect. Ask the patient to place each item (to be collected) in a separate paper bag as they undress.

Document the nature of the item on the paper bag and on the Forensic DNA Specimen page. When documenting the clothing, if collecting more than one item, change gloves between each item. This can be done at the end of the examination once the patient has left. Consider contacting the SARC doctor for advice.

Each bag should be sealed by folding over the top several times, securing with multiple layers of tape which go around the entire bag and then sealed with a strip of orange/red evidence tape at right angles to the tape which is signed across.

Paper bags and tamper-evident bags are supplied in the SARC EEK Kit and Male and Female Sexual Assault Examination Kits. WA Police also have a supply. 

Important Forensic Considerations

DNA contamination minimisation

The potential exists for DNA contamination, especially in a busy Emergency Department.

The following are recommended as a minimum:

  • Do not see the patient and then later the alleged assailant in the same examination room.
  • If forensic specimens are to be collected, wipe down the examination couch and specimen trolley with bleach or other cleaning reagent.
  • The examiner should wear a protective gown and change their gloves regularly during the examination and between forensic specimen collection sites.
  • Place a sterile theatre sheet on the examination couch and cover the patient with another sterile theatre sheet.
  • The patient should be given a clean gown to wear.
  • Place a sterile dressing pack on the specimen trolley and open Forensic Specimen swabs directly onto this.
  • Forensic swabs and smears should be closed and re-sheathed straight away after collection (no air-drying). 

Mandatory Reporting of Child Sexual Abuse

It is a legal requirement in Western Australia for doctors, nurses, midwives, teachers, police officers and boarding supervisors to report all reasonable beliefs of child sexual abuse to the Western Australian Department of Communities, Child Protection and Family Support.

If the patient is less than 18 years old, a mandatory report must be submitted even if the patient has involved the police.

Use the link below to make a mandatory report:

https://mandatoryreporting.dcp.wa.gov.au/Pages/MakeaReport.aspx

Contacting the Perth Sex Assault Squad – WA Police

For further information regarding WA Police processes call the following.

(08) 9428 1600 Monday – Friday (0800-1700)