Sexual assault in the adolescent

The evaluation of sexual assault in an adolescent must be a coordinated effort including both medical and psychological services, provided in a safe environment. Medical injuries must be evaluated, documented, and treated. Forensic evidence must be collected, and the possibility of sexually transmitted diseases and pregnancy must be addressed. Emotional support and referral for psychological services or further medical treatment should also be provided.

Other forms of maltreatment may occur in addition to sexual assault, and these must be assessed and documented. The medical examiner should be knowledgeable about the ways to approach and examine adolescents, and be aware of legal issues.

Ideally, the examiner should be part of a multidisciplinary team able to address the medical, psychological, and emotional needs of the adolescent. The medical examiner should be trained and skilled in the forensic procedures required for documentation and collection of evidence.[1] A team can ensure that comprehensive, consistent medical treatment is given, that evidentiary examinations are appropriately done, and that emotional support is provided.

Legal issues

There are specific issues that arise for the medical examiner when evaluating an adolescent who has been sexually assaulted.

In Canada, a sexual assault is an assault committed in circumstances of a sexual nature, such that the sexual integrity of the victim is violated. This involves intentionally applying force to the victim, directly or indirectly, and without consent. There are other elements of the law, which must be taken into consideration when evaluating an adolescent:

• Sexual activity without consent is always a crime, regardless of the age of the individual.
• Children under age 12 are never considered able to consent to sexual activity.
• Children 12 or older, but younger than 14 are deemed unable to consent to sexual acts except under specific circumstances involving sexual activity with their peers.
• Young persons 14 or older but younger than 18 are protected from sexual exploitation and their consent is not valid if the person touching them for a sexual purpose is in a position of trust or authority over them, or if the young person is in a relationship of dependency with the person.
• It is not a defence to these crimes for the accused to say that he or she believed the young person was older.
• It is recognized that adolescents, as part of their normal development, may engage in some sexual exploration. To allow for this, the law says that it is not a crime for two adolescents who are close in age to agree to sexual activity. The consent of both adolescents is, of course, essential.
• In cases where the alleged victim is 12 or older but younger than 14, the defence that the victim consented to the sexual activity can therefore be raised by an adolescent accused of sexual abuse. The court can accept this defence if the accused is less than 2 years older than the victim and is not yet 16 years of age. However, the defence is not available if the accused is in a position of trust or authority in relation to the victim, or if the victim is in a relationship of dependency with the accused.
• Other sexual offences include sexual interference (touching directly or indirectly for a sexual purpose with a part of the body or an object, any part of the body of a child under age 14), invitation to sexual touching (inviting, counseling, or inciting a child under 14 to touch directly or indirectly, with a part of the body or an object, the body of any person, including the child’s own body and the body of the person encouraging the touching), sexual exploitation of a young person, anal intercourse, and incest.[2]

Medical personnel who deal with adolescent sexual assault must know and understand the mandatory reporting laws in their province. In BC, this is the Child, Family and Community Service Act. It is always possible to consult child protection services if there is any uncertainty about reporting.

Many adolescents may be reluctant to report sexual assault because of embarrassment, fear of retribution, guilt, or lack of knowledge of their rights.[1,3] Some delay seeking medical care. Male victims are less likely to report than females.[1,4] The youth may feel that he or she contributed in some way to the act. In the case of acquaintance rape, there is an issue of credibility, as there may have been voluntary participation until the assault occurred.

Taking the history

Before beginning the evaluation, introductions are important. It is helpful to know who accompanied the adolescent and what their relationship is to him or her. The adolescent should be given the opportunity to choose whether to provide the history with or without a support person present.

The practitioner who will perform the medical exam needs to seek pertinent medical history, even though the formal investigative interview will be conducted by a member of the criminal investigative team. Informed consent must be obtained from the adolescent before any assessment is done. The adolescent should not be forced to have an examination.

Consent is valid only if the adolescent understands the information given about the assessment and examination and understands the limitations and reasons for the examination. The adolescent cannot give consent if there is cognitive impairment or if the adolescent is under the influence of drugs or alcohol.[5] The youth can withdraw consent at any time, to any part of the evaluation.

It is also important that consent be obtained for information to be discussed with a parent or guardian, and that consent be obtained for release of the medicolegal report. It is important to encourage the adolescent to disclose personal information to a parent or guardian, a close friend, or another support person. Confidentiality must be respected but the physician must also abide by the reporting laws in the province.

It is helpful to give an overview of the assessment, explaining the role of the examiner and letting the adolescent know that he or she has some control over how the assessment is done. The examiner should acknowledge a disclosure that may have been made to the referral source (police or social worker) about the nature of the abuse and the alleged perpetrator.

A direct but empathetic approach should be used to obtain a complete medical history. Specific protocols have been developed in many communities to help with accurate documentation of history as well as physical findings. For the most part, it is important to ask open-ended, non-leading questions, documenting well and recording the adolescent’s own words when possible. The adolescent should be allowed to tell his or her story in a narrative form. General details of the assault can help the examiner clearly assess the clinical findings and direct the physical examination (e.g., a speculum examination may be needed if there is a clear history of attempted penile penetration of the vagina). It is important to know whether oral, breast, or rectal contact or penetration occurred, whether a condom or lubricants were used, whether ejaculation occurred, whether the adolescent washed or douched, brushed teeth, urinated or defecated, or changed clothes after the assault.[6,7] It is important to know if pain or bleeding occurred or if any other physical injury occurred. A history of soreness or burning on urination after the assault is significant. Symptoms associated with defecation may occur after anal penetration. Oral sexual contact may result in a history of gagging, sore throat, or vomiting.[7]

Other significant information includes past history, family history, current medications (especially contraception), substance use, menstrual history (including the date of the last menstrual period), previous consensual sexual history and pregnancy, and previous history of sexual assault. Social history (family relationships, social supports, school experience) may also be relevant.

After obtaining the medical history, and with the consent of the adolescent, the medical examiner can fully explain the physical exam. Based on the given history, a determination can be made at this time whether the forensic kit will be needed.

Timing of examination

The timing of the examination depends both on the stability of the patient and on the urgency of need for forensic evidence. Generally, a forensic kit should be completed within 72 hours of a sexual assault.

This time limit is based on the likelihood of obtaining evidence (e.g., sperm) and identifying superficial mucosal injury. In a prepubertal adolescent, there may be limited value in completing the kit more than 24 hours after the assault.[6]

If an adolescent presents within 72 hours of the sexual assault, or if there is a history of genital discharge, pain, or bleeding, a history and physical exam should be completed as soon as possible so that forensic evidence can be collected.[8] If an adolescent presents after 72 hours, which is often the case, an evaluation is still important. Even though a kit will not be used, valuable physical evidence may be noted and documented. Appropriate assessment, evaluation, and treatment are necessary. If the last sexual contact occurred weeks or months before the disclosure, the physical examination can be delayed until an appropriate disclosure interview is completed.

If there is no indication to use the forensic kit, the decision to proceed with the physical exam should be based on the compliance of the adolescent, acute medical concerns, convenience for both the patient and the examiner, and the environment. The adolescent may choose to have the examination done over a series of visits.

The same decision-making process should be followed when the forensic kit is indicated but the adolescent declines to have the kit done. If the adolescent refuses any examination, the examiner must then consider if there is a need for other investigations (e.g., lab tests) and how treatment should be approached. The adolescent should be helped to fully understand the importance of gathering specimens immediately if legal action is to be considered.

When collecting forensic evidence, the examiner must ensure an unbroken chain of evidence. This means properly labeling, packaging, and documenting the origins of all forensic materials.

Physical examination

When describing the physical examination, the examiner should tell the adolescent patient that a complete “head to toe” assessment will be done, with the genital examination as one part of the whole. It is important to explain that the patient has the right to refuse any part of the examination at any time. The patient should also be told that he or she may choose a support person to be present during the examination, and be given privacy to change before the examination.

The general physical examination is usually a nonthreatening way to begin. Mental status assessment should also be done. Tanner staging of growth should be assessed and documented. The medical examiner must have knowledge and understanding of normal adolescent anatomy, particularly in the female, in order to appropriately assess and formulate an opinion about the physical findings.

When completing the genital examination of a female adolescent, the use of stirrups with the patient in the lithotomy position is helpful. A source of magnification such as an otoscope, a hand lens, or a colposcope can be useful. Colposcopy is helpful in identifying injury to the perineal area and hymen. Separation and traction techniques in the supine frog-leg position as well as in the knee-chest position can be used in adolescents as well as in children.[6] It is of paramount importance that the patient be comfortable during the positioning.

The external genitalia, inner thighs, labia majora, labia minora, clitoris, urethra, hymen, posterior fourchette, posterior navicular fossa, vaginal vault, and anus should be systematically reviewed and all findings documented.

Acute trauma may be apparent at the posterior fourchette. Abrasions, lacerations, or bruising may be noted. Acute injuries can resolve rapidly and penetrating trauma of the vagina and anus in the postpubescent female can heal completely without changes indicative of sexual assault.[9-11]

Complete and careful examination of the hymen in the adolescent female is extremely important. The estrogenized hymen is redundantly thick and elastic. The hymen can easily be examined in the adolescent by visual inspection, by using a cotton-tipped applicator, or by using the Foley catheter technique.[8] Breaks or tears can easily be missed unless the hymenal edge is explored specifically.[12] The hymenal edges are normally scalloped and folded in on themselves. Transections (complete clefts) of the posterior half of the hymen suggest and support a history of penetrating sexual abuse.[5] Hymenal tissue can stretch, without signs of injury, permitting penile penetration without tearing.[9,13] Partial tears of the hymen may appear as clefts or notches, which cannot be distinguished from normal adolescent anatomy.[11]

The forensic kit includes complete instructions with appropriate bags, swabs, labels, and containers for sample collection. Consent forms and documentation forms are often included, as well as drawings of the body and genitalia to indicate injuries. Some communities have modified kits to be used and the medical examiner may be able to determine which forensic sample is the most appropriate to collect in any given case.[4] If the forensic kit is used, evidence is generally collected from the clothing, body surface, and body fluids or cavities. All samples must be appropriately signed and labeled to maintain the chain of evidence.

If there is a history or evidence of penetration after examination of the hymen, a speculum examination can be done to obtain endocervical samples for Neisseria gonorrhoeae and Chlamydia trachomatis testing; vaginal samples for smears and wet mounts; samples for semen, DNA, or sperm; and a PAP smear. A microscope is necessary for the identification of sperm.

Genital examination of male adolescents must also be sensitive and age-appropriate. The genital examination should focus on the penis, testes, and anus.

In evaluating the anus, several positions may be used, including knee-chest or a lateral position. Anal findings could include scars, tears, fissures, flattened anal rugae, dilatation, or funnelling.

These patients may be at high risk for acquiring STDs and need to be tested for Neisseria gonorrhoeae and Chlamydia trachomatis. Some may have pre-existing infections from previous consensual sexual intercourse. Visual examination for herpes lesions and genital warts (condyloma acuminatum) must be done, as well as assessment for trichomoniasis (wet mount), and bacterial vaginosis (vaginal smear). Serologies for syphilis, hepatitis B, and HIV should also be done.

A pregnancy test should be performed if appropriate. Emergency oral contraception may be offered for pregnancy prophylaxis. In acute assaults, STD prophylaxis may be indicated. HIV prophylaxis should also be discussed. Tetanus and hepatitis B immunization status should be confirmed and updated if necessary. Arrangements may be made for a repeat pregnancy test in 2 weeks and follow-up STD tests if necessary.[9]

At the conclusion of the examination, the findings should be discussed with the adolescent and the parent or guardian (with the adolescent’s consent). Psychological supports should be organized and appropriate medical follow-up arranged.

Significance of findings

Lack of abnormal findings on genital examination does not negate a history of abuse. If adolescents do not report abuse in a timely fashion, physical signs of injury and other forensic evidence may not be present at the time of the examination.[14]

In a recent study of hymenal findings in adolescent women, the impact of tampon use and consensual sexual activity was examined. Complete clefts (transections) were commonly observed in subjects who reported consensual intercourse but uncommonly noted in groups who were not sexually active. Tampon use, sports participation, and previous pelvic exams didn’t alter genital findings in girls who were not sexually active.

Because the estrogenized hymen is elastic and distensible, it was difficult to measure and study the diameter of the hymenal opening in these adolescents.[15]

In one study, even when the offender admitted to vaginal penetration, normal or nonspecific findings were reported in 39% of victims.[16]

Another study found women without previous intercourse experience were more likely overall to have genital trauma than those with intercourse experience, but a significant proportion of survivors of sexual assault will not have visible genital injuries.[17]

Conclusion

The medical examiner must be aware of certain factors unique to adolescents when asked to evaluate sexual assault in this age group. An understanding of legal issues and reporting laws is important. Concerns around consent must be addressed. The examiner should be aware of how to reassure the adolescent and make the history-taking and examination process as comfortable as possible. Follow-up for specific medical and psychological services must be addressed and arranged. As part of a coordinated multidisciplinary team, the medical examiner can ensure comprehensive medical assessment and emotional support to the adolescent. Optimal management of adolescents who have been sexually assaulted can have a positive impact on these youth.

Competing interests
None declared.

Joan Fujiwara, MD

Dr Fujiwara is a practising family physician in the Youth Clinic at Surrey Memorial Hospital and an examining physician, with a special interest in adolescents, on the Health Evaluation and Assessment Liaison (HEAL) team at Surrey Memorial Hospital.