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National Protocol -Examination Process -Exam and Evidence Collection Procedures 2
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Examination and Evidence Collection Procedures- (cont)


Understand the implications of the presence or absence of seminal evidence1

The relevance of semen evidence in cases involving male suspects covers the spectrum, depending upon case facts. Semen is composed of cellular and liquid components known as spermatozoa (sperm) and seminal fluid. Semen evidence is valuable because it can be used to positively identify suspects. 2 However, it is critical to note that failure to recover semen is not an indication that a sexual assault did not occur. There are a number of reasons why semen might not be recovered in these cases: Assailants may have used condoms, ejaculated somewhere other than in an orifice or on patients’ clothes or bodies, or not ejaculated at all. Semen may have been depleted by frequent ejaculation prior to the sample in question.3  Chronic alcohol or drug abuse, chemotherapy, cancer, infection (e.g., mumps or tuberculosis), or congenital abnormalities also may suppress semen production. Other factors may contribute to the absence of detectable amounts of semen evidence. For example, significant time delays between the assault and collection of evidence may cause loss of semen evidence, semen may be washed away prior to the exam or improperly collected, and an object other than a penis may have been used for penetration.

Modify the exam and evidence collection to address the specific needs and concerns of patients.

Examiners should be aware that patients’ beliefs might affect whether and how certain evidence is collected. For example, patients from certain cultures or religious backgrounds may view hair or fingernails as sacred and decline collection of hair evidence. (For more information on this topic, see A.2. Victim-Centered Care. Accommodating mobility impairments is discussed in footnotes for this chapter. For details on accommodating communication needs and responding to verbal and nonverbal cues, see C.4. The Medical Forensic History.)

Explain exam and evidence collection procedures to patients.

Whatever the methods used for seeking informed consent from patients for the exam and evidence collection, the full nature of procedures and options should be explained. Examiners may provide some basic information prior to starting the exam and additional information as the exam proceeds. For example, if specialized equipment is used, examiners can explain to patients, at some point prior to its use, what the equipment is, how it will be used, for what purpose, and how long the procedure will take. Encourage patients to ask questions and to inform examiners if they need a break or do not want a particular part of the exam or evidence collection done. (For more information on obtaining informed consent of patients, see A.3. Informed Consent.)

Conduct the general physical and anogenital exam and document the physical findings on body diagram forms.4

In addition to instructions included in the evidence collection kit, the exam should be guided by the scope of informed consent and the medical forensic history.

In the course of the exam, examiners may question patients about trauma related to the assault. These questions should be specific enough to yield clinically relevant information. For example, simply asking if patients are injured or hurt anywhere is not focused enough—they may not know where they are injured until examined and/or asked questions such as if they hurt in specific body locations.

General physical examination. Obtain patients’ vital signs, note the date and time of the exam, physical appearance, general demeanor, behavior, and orientation, and condition of clothing on arrival. Record all physical findings (which include observable or palpable tissue injuries; physiologic changes; and foreign materials such as grass, sand, stains, dried or moist secretions, or positive fluorescence) on body diagram forms. Be observant for redness, abrasions, bruises, swelling, lacerations, fractures, bites, burns, and other forms of physical trauma. Potential traumatic findings should be palpated to assess for tenderness and induration. On dark-skinned individuals, it may be difficult to identify these areas and they may need to be sought out specifically.

Anogenital examination.5 During the female genital exam,6 examine the external genitalia and perineal area for injury, foreign materials, and other findings in the following areas: abdomen, thighs, perineum, labia majora, labia minora, clitorial hood and surrounding area, perurethral tissue/urethral meatus, hymen,7 fossa navicularis, and posterior fourchette. The use of a colposcope during the external genital exam enhances viewing microscopic trauma and may provide photographic documentation.8

Then examine the vagina and cervix for injury, foreign materials, and foreign bodies. Use a colposcope or other magnifying device if available. In some jurisdictions, toluidine blue dye may be used to highlight trauma, either with or without the use of a colposcope.9 Examine the buttocks, perianal skin, and anal folds for injury, foreign materials, and other findings. If rectal penetration is reported or suspected, an anoscope can be used as a tool to identify and evaluate trauma (it may also be used to help obtain anal swabs and trace evidence).

For male patients, examine the external and perineal area for injury, foreign materials, and other findings, including from the abdomen, buttocks, thighs, foreskin, urethral meatus, shaft, scrotum, perineum, glans, and testes. Document whether patients are circumcised.

Documentation of findings. Record findings from the general physical and anogenital exam on appropriate body diagram forms. Detailed descriptions of findings should be provided as required. During the exam, collect evidence as specified in the evidence collection kit and photograph anatomy involved in the assault according to jurisdictional policy. Follow jurisdictional policy regarding documentation, photography, and collection of bite mark evidence.10

 Table of Contents Exam and Evidence Collection Procedures (continued pg 3)




1 Drawn from the West Virginia Protocol for Responding to Victims of Sexual Assault, 2082, pp. 32, and New Hampshire’s Sexual Assault: A Hospital Protocol for Forensic and Medical Examination, 1998, pp. 26–27.

2 In the absence of sperm, certain seminal fluid components may be used to identify semen.

3 If assailants who had a vasectomy ejaculated, their seminal fluid would not contain sperm.

4 This section on performing the exam is primarily drawn from the American College of Emergency Physicians’ (ACEP) Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient, 1999, pp. 103–107. Much of the ACEP exam procedures were based on the California Medical Protocol for Examination of Sexual Assault and Child Sexual Abuse Victims.

5 If patients are mobility impaired, review their history at this stage. In patients with spinal cord injury (SCI), the level of injury and any history of autonomic dysreflexia will have to be noted and given special attention. Other considerations in these patients are histories of muscle spasm and triggers for both muscle spasm and autonomic dysreflexia. Examiners should be sure to ask about things such as whether these patients have ever had a speculum exam, what this experience was like, what the most comfortable position would be for the anogenital exam, and any history of autonomic dysreflexia with a speculum exam. (Commonwealth of Massachusetts’s SANE Protocol, 2002, p. 36.) Transgender individuals with a masculine identity and those with a constructed vagina may sustain additional physical and emotional damage when vaginally assaulted.

6 Some patients may not have previously had a gynecological exam and need a detailed explanation and support during this part of the exam. (Drawn from L. Zarate, 2003, Suggestions for Upgrading the Cultural Competency Skills of SARTs, Arte Sana Web site, 2003.)

7 The Tanner Scale of Secondary Sexual Development is a sexual maturity rating scale that defines a child’s stage of puberty. (American Professional Society on the Abuse of Children, Glossary of Terms and the Interpretation of Findings for Child Sexual Abuse Evidentiary Examinations, p. 7.) These developmental stages are relevant to the interpretation of physical findings in child and adolescent cases. There is a relationship between Tanner Stages and hymenal development. Physical findings must be evaluated in the context of hymenal development for the interpretation of findings. (The California Medical Protocol for Examination of Sexual Assault and Child Sexual Abuse Victims, 2001, p. 61.)

8 Colposcopes have magnifying lenses ranging from 4x to 30x power and can have 35-mm camera or video camera attachments. Colposcopes have a green filter that enhances the visualization of scars, unusual vascular patterns, and genital warts. Examiners can use the colposcope to obtain magnified images of the oral pharynx, genital, and rectal areas. Minor skin and/or mucosal trauma such as abrasions, lacerations, petechiae, focal edema, hymeneal tears, and anal fissures are more easily seen with magnification, and photographs can be taken for documentation. Attached video cameras can also record images. (Drawn from the California Medical Protocol for Examination of Sexual Assault and Child Sexual Abuse Victims, 2001, p. 58).

9 The use of toluidine blue dye is controversial in some jurisdictions (e.g., it may be perceived by the court as changing the appearance of the tissue) and not universally used. When employed, toluidine blue dye (1-percent aqueous solution) should be applied by cotton swab before any internal or digital speculum examination. Although DNA evidence will be preserved, care should be taken to avoid letting dye enter the vaginal vault. Excess dye may be blotted away with 1-percent acetic acid solution or lubricating jelly. Toluidine blue dye cannot separate consensual from nonconsensual lesions. Patients should be advised that small traces of the dye might shed in their clothing over the 2 days following the exam. (Information on use of this dye is drawn from the American College of Emergency Physicians’ Evaluation and Management of the Sexually Assaulted or Abused Patient, 1999, p. 117.)

10 In addition to documenting, swabbing, and photographing bite marks, an odontologist may need to make casts. Without a cast, teeth cannot be matched to suspects. The American College of Emergency Physicians’ Evaluation and Management of the Sexually Assaulted or Abused Patient, 1999, pp. 111–112, offers guidelines for bite mark documentation.

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