Non-genital injuries to women who are sexually assaulted In the US, victims' rights include the right to have a victims advocate preside over every step of the medical/legal exam to ensure sensitivity towards victims, provide emotional support, and minimize the risk of re-traumatization. Victims are to be informed of this immediately by law enforcement or medical service providers. Emergency rooms of many hospitals employ sexual assault nurse/forensic examiners (SAN/FEs) with specific training to care for those who have experienced a<unk>  or sexual assault. They are able to conduct a focused medical-legal exam. If such a trained clinician is not available, the emergency department has a sexual assault protocol that has been established for treatment and the collection of evidence. Staff are also trained to explain the examinations in detail, the documentation and the rights associated with the requirement for informed consent. Emphasis is placed on performing the examinations at a pace that is appropriate for the person, their family, their age, and their level of understanding. Privacy is recommended to prevent self-harm. Non-genital injuries Physical assessment Many<unk> s do not result in serious physical injury. The first medical response to sexual assault is a complete assessment. This general assessment will prioritize the treatment of injuries by the emergency room staff. Medical personnel involved are trained to assess and treat those assaulted or follow protocols established to ensure privacy and best treatment practices. Informed consent is always required prior to treatment unless the person who was assaulted is unconscious, intoxicated or does not have the mental capacity to give consent. Priorities governing the physical exam are the treatment of serious life-threatening emergencies and then a general and complete assessment. Some physical injuries are readily apparent such as, bites, broken teeth, swelling, bruising, lacerations and scratches. In more violent cases, the victim may need to have gunshot wounds or stab wounds treated. The loss of consciousness is relevant to the medical history. If abrasions are found, immunization against tetanus is offered if 5 years have elapsed since the last immunization. Diagnostic testing After the general assessment and treatment of serious injuries, further evaluation may include the use of additional diagnostic testing such as x-rays, CT or MRI image studies and blood work. The presence of infection is determined by sampling of body fluids from the mouth, throat, vagina, perineum, and anus. Forensic sampling Victims have the right to refuse any evidence collection. Victims advocates ensure the victims' wishes are respected by hospital staff. After the physical injuries are addressed and treatment has begun, then forensic examination proceeds along with the gathering of evidence that can be used to identify and document the injuries. Such evidence-gathering is only done with the complete consent of the patient or the caregivers of the patient. Photographs of the injuries may be requested by staff. At this point in the treatment, if a victims' advocate had not been requested earlier, experienced social support staff are made available to the patient and family. If the patient or the caregivers (typically parents) agree, the medical team utilizes standardized sampling and testing usually referred to as a forensic evidence kit or "rape kit". The patient is informed that submitting to the use of the<unk>  kit does not obligate them to file criminal charges against the perpetrator. The patient is discouraged from bathing or showering to obtain samples from their hair. Evidence gathered within the past 72 hours is more likely to be valid. The sooner that samples are obtained after the assault, the more likely that evidence is present in the sample and provides valid results. Once the injuries of the patient have been treated and she or he is stabilized, the sample gathering will begin. Staff will encourage the presence of a<unk> /sexual assault counselor to provide an advocate and reassurance. During the medical exam, evidence of bodily secretions is assessed. Dried semen that is on clothing and skin can be detected with a fluorescent lamp. Notes will be attached to those items on which semen has been found. These specimens are marked, placed in a paper bag, and are marked for later analysis for the presence of seminal vesicle-specific antigen. Though technically, medical staff are not part of the legal system, only trained medical personnel can obtain evidence that is admissible during a trial. The procedures have been standardized. Evidence is collected, signed, and locked in a secure place to guarantee that legal evidence procedures are maintained. This carefully monitored procedure of evidence collection and preservation is known as the chain of evidence. Maintaining the chain of evidence from the medical examination, testing, and tissue sampling from its origin of collection to court allows the results of the sampling to be admitted as evidence. Photography is often used for documentation. After the examination Some physical effects of the<unk>  are not immediately apparent. Follow up examinations also assess the patient for tension headaches, fatigue, sleep pattern disturbances, gastrointestinal irritability, chronic pelvic pain, menstrual pain or irregularity, pelvic inflammatory disease, sexual dysfunction, premenstrual distress, fibromyalgia, vaginal discharge, vaginal itching, burning during urination, and generalized vaginal pain. The World Health Organization recommends offering prompt access to emergency contraceptive medications which can significantly reduce risk of an undesired pregnancy if used within 5 days of<unk> ; it is estimated that about 5% of male-on-female<unk> s result in pregnancy. When<unk>  results in pregnancy, abortion pills can be safely and effectively used to end a pregnancy up to 10 weeks from the last menstrual period. In the US, federal funding is available to cover the cost of abortion services for pregnancies that occur as a result of<unk> , even in states that do not offer public-funding for abortion services. Genital injuries An internal pelvic exam is not recommended for sexually immature or prepubescent girls due to the probability that internal injuries do not exist in this age group. However, an internal exam may be recommended if significant bloody discharge is observed. A complete pelvic exam for<unk>  (anal or vaginal) is conducted. An oral exam is done if there have been injuries to the mouth, teeth, gums, or pharynx. Though the patient may have no complaints about genital pain signs of trauma can still be assessed. Before the complete bodily and genital exam, the patient is asked to undress, standing on a white sheet that collects any debris that may be in the clothing. The clothing and sheet are properly bagged and labeled along with other samples that can be removed from the body or clothing of the patient. Samples of fibers, mud, hair, or leaves are gathered if present. Samples of fluids are collected to determine the presence of the perpetrator's saliva and semen that may be present in the patients mouth, vagina or rectum. Sometimes the victim has scratched the perpetrator in defense and fingernail scrapings can be collected. Injuries to the genital areas can include swelling, lacerations, and bruising. Common genital injuries are anal injury, labial abrasions, hymenal bruising, and tears of the posterior fourchette and fossa. Bruises, tears, abrasions, inflammation and lacerations may be visible. If a foreign object was used during the assault, x-ray visualization will identify retained fragments. Genital injuries are more prevalent in post-menopausal women and prepubescent girls. Internal injuries to the cervix and vagina can be visualized using colposcopy. Using colposcopy has increased the detection of internal trauma from six percent to fifty-three percent. Genital injuries to children who have been<unk> d or sexually assaulted differ in that the abuse may be on-going or may have happened in the past after the injuries heal. Scarring is one sign of the sexual abuse of children. Several studies have explored the association between skin color and genital injury among<unk>  victims. Many studies found a difference in<unk> -related injury based on race, with more injuries being reported for white females and males than for black females and males. This may be because the dark skin color of some victims obscures bruising. Examiners paying attention to victims with darker skin, especially the thighs, labia majora, posterior fourchette, and fossa navicularis, can help remedy this. Infections The presence of a sexually contracted infection can not be confirmed after<unk>  because it cannot be detected until 72 hours afterwards. The person who was<unk> d may already have a sexually transmitted infection and if diagnosed, it is treated. Prophylactic antibiotic treatment for vaginitis, gonorrhea, trichomoniasis and chlamydia may be performed. Chlamydial and gonococcal infections in women are of particular concern due to the possibility of ascending infection. Immunization against hepatitis B is often considered. After prophylactic treatment is initiated, further testing is done to determine what other treatments may be necessary for other infections transmitted during the assault. These are: * Serum hepatitis B surface antigen assay * Microscopic evaluation of vaginal discharge (saline wash and staining) * Cultures for Neisseria gonorrhoeae and Chlamydia trachomatis from each penetrated location * Serum Venereal Disease Research Laboratory test * Complete blood count (CBC) * Liver function tests * Serum creatinine
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