Sexual Assault and Forensic Exam Offers in the Emergency Department: A Retrospective Study

TL;DR

This study finds that patients with signs of mental illness or substance use are less likely to be offered a forensic exam after reporting sexual assault in the emergency department.

Contribution

The study identifies clinician concern for acute mental illness or substance use as a key barrier to offering forensic exams for sexual assault survivors.

Findings

Patients with clinician concern for mental illness or substance use were significantly less likely to be offered a forensic exam.

Uninsured patients were overrepresented in the study compared to the local population.

Younger patients and those arriving ambulatory were more likely to be offered a forensic exam.

Abstract

Patients who report sexual assault in the emergency department (ED) have a legal right to a forensic exam. Emergency departments that do not provide such exams must offer transfer to a forensic site. Little is known about the factors influencing whether patients are offered a forensic exam and complete the transfer. In this study we aimed to identify patient characteristics associated with being offered a forensic exam in an ED that does not perform them on site.

We conducted a retrospective chart review of adult patients presenting to a single, urban, academic ED between January 2017–December 2019. The ED receives over 75,000 visits annually and refers patients to an external site for forensic exams. Using keywords “sexual assault” or “rape” we identified charts that included whether the visit involved an initial report of sexual assault. Charts were abstracted for demographics, insurance status, psychiatric history, clinician concern for acute mental illness or substance use, and mode of arrival. The primary outcome was whether a forensic exam was offered. Statistical analyses included chi-square tests and penalized logistic regression.

Of 167 charts reviewed, 108 met inclusion criteria. Of these, 94 patients (87.0%) were offered a forensic exam and 14 (64.8%) accepted transfer. Patients who were offered exams were younger (mean age 29.9 vs 36.8 years, P = .05), more likely to arrive ambulatory (69.1 vs 42.9%, P = .02), and less likely to have a psychiatric history (31.9 vs 71.4%, P = .01). Clinician concern for acute psychiatric illness or substance use was significantly associated with not offering a forensic exam (64.3 vs 16.0%, P < .001). In regression analysis, this concern was the only independent association of not being offered a forensic exam (adjusted odds ratio 0.16, 95% CI, 0.03–0.76, P = .02). Additionally, 23.1% of patients were uninsured, significantly higher than the local rate of 2.7%.

Patients in the ED who report sexual assault are less likely to be offered a forensic exam if they present with signs of acute mental illness or substance use disorder. These findings highlight the need for standardized protocols and advocacy to ensure equitable access to forensic exams, especially for patients with behavioral health needs or without insurance.