One key tenet of sexual assault care is that patients must be able to provide consent for the medical forensic examination; patients have the right to refuse any or all parts of the examination.^9,10 Also, they have the right to decide what happens with the evidence collected.

Patients who are intoxicated may be not be capable of providing informed consent or actively participating in the exam process due to their level of intoxication. In these cases, patients should be observed and allowed time for detoxification. After clinical sobriety, options regarding reporting and the medical forensic examination can be re-reviewed with patients. Some patients who are unconsciousness, head-injured, or have other serious traumatic or medical conditions may remain unable to consent for a much longer period. During this prolonged period, evidence may be lost or degraded. Therefore, emergency departments should have protocols for handling consent and examination in these unconscious/nonconsentable patients.

Many advocate for collecting the evidence and then waiting for patients or their legal surrogate to decide what is done with the evidence. Emergency departments and SANE programs should have a policy describing how to handle intoxicated, unconscious, or incapacitated victims of sexual assault.⁹

Case Resolution

The patient remains hemodynamically stable and is allowed to sober up in the emergency department. At that time, the patient still wants to undergo medical forensic examination without reporting the incident to the police. The patient is transferred to a SANE-designated facility and undergoes examination and evidence collection.

Dr. Riviello is chair of emergency medicine at Crozer-Keystone Health System and medical director of the Philadelphia Sexual Assault Response Center.

Dr. Rozzi is an emergencyphysician, director of the Forensic Examiner Team at WellSpan York Hospital in York, Pennsylvania, and chair of the Forensic Section of ACEP.

References

1. Black MC, Basile KC, Breiding MJ, et al. The national intimate partner and sexual violence survey: 2010 summary report. Centers for Disease Control and Prevention website. Accessed Oct. 15, 2018.
2. Campbell R, Patterson D, Adams A, et al. A participatory evaluation project to measure SANE nursing practice and adult sexual assault patients’ psychological well-being. J Forensic Nurs. 2008;4(1):19-28.
3. Ericksen, J, Dudley C, McIntosh G, et al. Clients’ experiences with a specialized sexual assault service. J Emerg Nurs. 2002:28(1):86-90.
4. Fehler-Cabral G, Campbell R, Patterson D. Adult sexual assault survivors’ experiences with sexual assault nurse examiners (SANEs). J Interpers Violence. 2011;26(18):3618-3639.
5. Emergency contraception. Guttmacher Institute website. Accessed Oct. 15, 2018.
6. SANE program and development guide. Office for Victims of Crime website. Accessed Oct. 15, 2018.
7. Background on VAWA 2005, VAWA 2013, and forensic compliance. End Violence Against Women International website. Accessed Oct. 15, 2018.
8. Unreported/anonymous sexual assault kits. The National Center for Victims of Crime website. Accessed Oct. 15, 2018.
9. Carr ME, Moettus AL. Developing a policy for sexual assault examinations on incapacitated patients and patients unable to consent. J Law Med Ethics. 2010;38(3):647-653.
10. SANE program and development guide: Informed consent and patient confidentiality. Office for Victims of Crime website. Accessed Oct. 15, 2018.