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Sexual Assault: The
Role of the Pre-hospital
Tiffany Kuehl, MD
Spokane Emergency Medicine Associates
Deaconess Emergency Department
To be aware of the scope of the problem
To become familiar with the medico-legal
procedure regarding sexual assault
To understand how pre-hospital providers
may most effectively assist victims of sexual
Legal definition
Rape: A person is guilty of rape by engaging
in sexual intercourse with another person by
forcible compulsion, or when the victim is
incapable of consent by reason of being
physically helpless or mentally incapacitated,
or where the victim did not give verbal
consent, or lack of consent was expressed
through the victim’s conduct.
Rape is a felony. (felony class A to class C, depending on
The scope of the problem
In the state of Washington, at least one out of every
three women will be victims of sexual violence
during their lifetime. One in six will be raped. (source:
Rape in Washington: A Report to the State)
According to the WA state criminal justice Data
book, there were 2772 reported rapes in 2005.
In 2004 WA state community sexual assault
programs served over 10,000 victims of sexual
assault. (source: Office on Victim Crime Advocacy, 2004)
Somewhere in America, every 2 minutes a woman is
raped. (source: US Dept. of Justice)
The scope of the problem
More than half of all rapes of women occur
before age 18; 22% of these occur before
age 12. (source: WA Dept. of Health data)
At least 30% of all female homicide victims
are killed by a current or former intimate
partner. (source: WA Dept. of Health data)
In an HMO study, abused women cost the
health plan 92% more than the general
female population. (source: Wisner,C.L., Gilmer,T.P.,
Saltzmann,L.E., and Zink,T.M. Intimate partner violence against women: Do
victims cost health plans more? J. Fam. Practice 48(6):439-43)
What happens in the emergency
Victims will go through triage and will be
medically examined.
They may be offered counsel with a sexual
assault advocate.
They will be given an opportunity to report to
They will have the option to undergo an
evidence collection process.
Medications for the prevention of STDs and
pregnancy will be offered.
The medical exam
The medical exam establishes the presence
of injury and need for treatment.
In the majority of cases (70-85%) there are
no visible injuries despite forcible rape.
Therefore, the medical exam CANNOT
reliably determine whether a rape has
The legal aspect
Age of consent: A person thirteen years of age or
older may request medical attention or a forensic
exam without the consent of their parents.
Mandatory reporting law: Any sexual assault of a
minor (under age 18) must be reported to police
and/or Child Protective Services.
In WA, the law assumes that persons under the age
of 16 are not old enough to give consent for sex.
Any sexual act with someone under age 16 is
defined as statutory rape.
The legal aspect
If an injured victim of domestic violence is
treated by a physician or nurse who does not
inquire about abuse or who accepts an
unlikely explanation of the injury, and the
patient subsequently sustains further injury
resulting from abuse, the physician or nurse
could become liable for those injuries.
The sexual assault evidence
collection kit
It is the victim’s choice to report the crime to
police and to have a SA kit done.
DNA evidence is not valid 72 hours after the
assault, so a kit will not be offered if more
than 3 days have elapsed.
The SA kit does not determine if a rape has
occurred. It is used for DNA identification
The sexual assault evidence
collection kit
The SA kit goes to the custody of the police
after it is complete, therefore a police report
must be made in order to perform evidence
The SA kit is only opened/analyzed when the
legal case goes to trial.
What is the SA kit?
It involves collection of DNA from the victim’s
Blood and urine is taken from the victim.
Hair samples are collected.
Photographs may be taken (with their
Cotton swabs are used to collect samples
from the mouth, vagina, cervix, and anus.
(depending on type of assault)
What you can do
Be sensitive to the emotional state of the
Inform them or their rights: they have a legal
right to have a support person accompany
them, to have a free medical examination,
and to have emergency contraception
provided by the hospital.
Reassure them that the information they give
to medical providers will remain confidential.
Reassure them that they are safe now.
What you can do
Remind the victim to write down the police
report number and name of the officer who
took the report. Have them keep it in a
secure place.
Victims have the right to report to police
regardless of the time that has passed after
the assault.
Victims do not legally have to report their
immigration status to the police when
reporting a crime or rape.
What you can do
Don’t ask them to report the whole story
to you, but if they volunteer it, document
the words verbatim (use their words)
and communicate to the ER staff.
 Protect the evidence.
Protecting the evidence
Don’t disturb items at the scene before arrival of
Document or report to ER or police regarding the
scene and events.
Encourage the victim to avoid showering, eating,
drinking liquids, or changing clothes.
Encourage the victim to bring the clothes they wore
during the assault (ask victim to place items into a
bag, or you use gloves), and to bring a change of
clothes to the hospital.
Child sexual abuse
In this case, a forensic exam may be deferred
to a more specialized team.
A medical exam may still be performed on
those that have had a recent abuse event to
assess for injury.
It is important to encourage transport to ER
so that home safety may be assessed.
Questions and Concerns?
Have you encountered a case in which you
didn’t know what to do at the scene?
Are there cases you have had that you
What are some biases you have witnessed?
Have you felt judgmental about certain
Post Test
There are no visible genital injuries in 70-85% of rape cases.
Victims have 30 days after the assault to report the incident to
The purpose of a sexual assault evidence collection kit is to
determine if a rape has occurred.
One in 6 women in Washington state will be a victim of rape at
some point in their lifetime.
An SA kit can be performed without making a police report.
Have a Great Summer!!
Renee Anderson
[email protected]
Fax: 1-509-232-8344