Speculum examinations: Clinicians' attitudes and approaches to obtaining consent in a sexual assault context

Abstract

Background: In many countries, a forensic medical examination by a trained professional is offered to people who have experienced recent sexual assault. The consultation may include a vaginal speculum examination to visualise injuries and collect forensic evidence, but not all patients will consent to the examination. Clinicians' attitudes to a speculum examination in a sexual assault context and the consequent wording when obtaining consent may influence uptake rates and ultimately health outcomes for sexual assault survivors.

Objectives: This survey study identifies (i) factors affecting clinician attitudes towards the use of speculum examinations in sexual assault forensic medical examinations; (ii) situations in which they would offer a speculum examination; and (iii) approaches to seeking consent.

Methods: An online survey was sent to all eligible forensic examiners working in sexual assault services across New South Wales (NSW), Australia (n = 100), between August and September 2019. The survey recorded demographic data, experience with speculum examinations, opinions regarding the main purpose of the speculum examination, circumstances in which clinicians would offer a speculum examination, and the wording of their consent process based upon two detailed clinical scenarios (differing only in the hours elapsed since the assault (24 h vs 72 h)). A mixed method approach was used to analyse the data and was completed using SPSS and NVivo.

Results: Of the 100 invited participants, there were 32 respondents. Twenty-eight respondents (87.5%) stated that the main purpose of a speculum examination is to both check for injuries and collect evidence. Clinicians were more likely to offer a speculum examination to patients presenting with symptoms (i.e., pelvic pain, bleeding) or presenting more than 24 h after the event. Twenty-seven participants (84.4%) stated that patient-centred factors (i.e., time of presentation, patient comfort with speculum examination) were the main influences in whether they would/would not offer a speculum examination. Clinicians felt more comfortable performing speculum examinations in a forensic setting if they felt comfortable performing speculum examinations in a non-forensic setting (p = 0.004) and less comfortable as time increased from introductory sexual assault training (p = 0.0029). Eight participants (26.7%) would not offer a speculum examination acutely (< 24 h post assault) but only one (0.03%) would not offer it 72 h post assault.

Conclusions: This study is the first to explore clinicians' attitudes towards the speculum examination component of the adult sexual assault forensic medical examination and provides foundations for future research. Current guidelines should be reviewed and updated to ensure that speculum examinations are routinely offered, rather than only when endocervical samples are being considered, to ensure potential injuries are not missed.