The Medical-Forensic Examination: Structure and Patient Communication

The SANE's first task on meeting a patient is not to begin the examination. It is to introduce herself, explain her role clearly (a nurse with specialist forensic training, not a detective, not a social worker, not a counsellor), and give the patient an accurate picture of what the examination involves and what will happen to the evidence. Many patients have no idea that they can refuse any part of the examination and still have the rest proceed. Telling them this at the outset changes the dynamic: they are a participant, not a subject.

The examination space matters. A dedicated SANE suite with a private waiting area, a patient-controlled door, civilian clothes on staff, and examination furniture that does not replicate a standard gynaecology room is measurably better for patient cooperation and disclosure than a curtained-off bay in a busy emergency department. Where a dedicated suite is not available, the SANE can partially recreate the conditions: non-clinical framing of the conversation, a support advocate in the room if the patient wants one, and explicit control given to the patient over pacing.

The SANE takes a focused medical history, not an investigative one. The questions aim to direct evidence collection (what body areas were involved, what acts occurred) and to identify clinical needs (current medications, contraceptive status, last menstrual period, hepatitis B vaccination status). The SANE does not assess whether the account is credible, probe for inconsistencies, or ask questions aimed at corroborating or refuting the complaint. That is the detective's role, and conflating the two damages both the clinical relationship and the evidentiary value of the examination.

• Time and date: elapsed time since the assault determines which biological samples are still likely to be present and whether the 72-hour HIV PEP window remains open.
• Post-assault activity: whether the patient has bathed, urinated, defecated, changed clothing, eaten, or drunk. Each activity can reduce the yield of specific samples.
• Nature of the assault: body areas involved, acts that occurred, use of foreign objects or condoms. This directs which swab sites are clinically indicated.
• Relevant medical history: prior pelvic injuries, surgeries, pre-existing conditions affecting the examination area, and medications (particularly anticoagulants that would affect bruising interpretation).

Before the anogenital examination, the SANE conducts a systematic head-to-toe examination to document all injuries on the body surface. This is not ancillary: in most sexual assaults, particularly acquaintance and partner assaults, extra-genital injuries to the neck, arms, thighs, and wrists are more common than anogenital injury and may be the most probative evidence. An examination that begins and ends with the pelvis misses injuries that juries and pathologists find highly significant.

Each injury is documented by location using anatomical landmarks, size (measured with a ruler in the photograph), appearance (contusion, abrasion, laceration, bite mark, patterned injury), colour (relevant for bruise ageing), and whether it appears fresh or older. Colposcopic photography is used where magnification aids documentation. Alternative light source (ALS) examination may reveal bite marks, semen traces, or bruising not visible in white light. Oral and skin trace swabs are taken before any injuries are cleaned or treated.

Anogenital examination uses a standardised anatomical vocabulary to ensure that findings documented by one SANE can be understood without ambiguity by another clinician, a pathologist, or a court. The clock-face reference system (0-12 o'clock) gives positions of findings in both the vaginal and anal area. Hymenal configurations are described using established terminology (annular, crescentic, fimbriated, redundant) rather than lay terms. Findings are classified using the Unified Terminology for Child and Adolescent Sexual Abuse Medical Findings or equivalent adult frameworks.

A critical evidence-based point that SANEs must understand and communicate: the absence of anogenital injury does not indicate that assault did not occur. Studies consistently show that fewer than half of reported sexual assault victims have any anogenital injury, and among those with injury, the injuries are often minor. The mucosa heals quickly; penetration, particularly in cases involving prior sexual activity, may produce no lasting physical sign. Overclaiming injury significance, and under-explaining injury absence, are both errors with serious consequences in court.

Speculum examination allows visualisation of the vaginal walls and cervix and is the standard approach for evidence collection in adult post-pubertal patients. Alternatives exist where speculum use is not clinically indicated or is declined by the patient: blind-swab technique and labial separation with a saline-moistened swab can recover biological material without speculum insertion. The choice is documented with the clinical rationale.

The paediatric medical-forensic examination differs from adult practice in positioning, technique, scope, and the critical importance of coordination with child protection services. Pre-pubertal children are examined in the supine frog-leg position or, for anal examination, in the prone knee-chest position. The lithotomy position used in adult gynaecology is unnecessary and distressing for children.

A speculum is not used in pre-pubertal patients. Examination of the hymen uses labial separation and labial traction techniques that allow visualisation without instrumentation. The examination is more often limited in scope than an adult examination: a thorough examination of the hymen and anus is conducted, but the vaginal walls and cervix are not accessible or appropriate.

History-taking from children follows child-forensic interviewing principles: open-ended questions, no leading prompts, no presumption of specific events, and ideally a single interview in a child advocacy centre before the medical examination to minimise the number of times the child must recount the events. The SANE's history is deliberately limited to what is clinically necessary. Normal variants in pre-pubertal anatomy (a wide hymenal orifice, hymenal tags, midline avascular areas) must be distinguished from injuries, and a SANE practising paediatrics should be familiar with the Adams classification system and the supporting research literature.

Patients have the right to refuse any component of the medical-forensic examination at any point, including after consent has been given. They may consent to the general examination but decline the anogenital component. They may consent to evidence collection but refuse medical treatment. They may ask the SANE to stop at any point and resume later, or not resume at all. The SANE's task is to ensure the patient understands what declining each component means for evidence availability and medical care, without coercing a particular choice.

Safety planning is a structured healthcare conversation, not a law enforcement function. The SANE assesses whether the perpetrator has ongoing access to the patient, whether there are dependent children in the home, and what the patient's immediate plan is. The SANE provides referral information for crisis services, domestic violence services, and follow-up healthcare. The SANE does not decide the safest course of action for the patient. The SANE provides information, and the patient decides.