Sexual assaults are distinguished from other assaults by forcible, inappropriate sexual behavior upon a person without consent. In the course of a sexual assault, any injury may be inflicted on the victim, up to and including life-threatening multiorgan system trauma.
Signs and symptoms
Signs of sexual assault include evidence of the use of force such as the following:
Presence of blood and/or sperm
Contusions
Lacerations
Abdominal trauma
Joint dislocation
Mechanical back pain
Abruptio placentae
Lesions caused by forceful genital penetration
In addition to the physical trauma, sexual assault can result in significant mental suffering for victims and lead to posttraumatic stress disorder (PTSD). It can also result in unwanted pregnancy and victims may also be exposed to sexually transmitted diseases (STDs).
See Clinical Presentation for more detail.
Diagnosis
Laboratory studies
Urine or serum pregnancy tests should be obtained in women of childbearing age. Baseline testing for STDs, although controversial, may be carried out, including the following:
Serologic tests for syphilis, hepatitis B, and HIV
Cultures of exposed body sites, as appropriate, to evaluate for STDs (eg, oral, throat, vaginal, and rectal)
Wet mount and culture of a vaginal swab specimen to evaluate for Trichomonas vaginalis, bacterial vaginosis, and candidiasis
Procedures
Colposcopy, where available, may have considerable value in documentation, because it allows photographic recording of injuries, including lesions caused by forceful genital penetration. Anoscopy may be performed in male victims and may be combined with colposcopy in female victims.
See Workup for more detail.
Management
Emergency department care
Medical intervention in sexual assault is focused on prevention of unwanted pregnancy and STDs. This includes the administration of antibiotics (eg, ceftriaxone, metronidazole, and azithromycin) as prophylaxis against diseases such as gonorrhea and chlamydia.
Emergency contraception is offered if the patient’s pregnancy test results are negative. Additional treatment for sexual assault includes updating the patient’s tetanus status, if necessary, and administration of hepatitis B vaccine if the patient has not previously been vaccinated. Follow-up doses of the vaccine are administered over the next few months.
Counseling
If available, a consultation with a sexual assault counselor should be offered in the emergency department. The patient should also be referred to a sexual assault center for aftercare and community resources. Given the long-term emotional and psychosocial impact of sexual assault on the victim, aftercare is vital.
Patients who come to the emergency department after sexual assault present several challenges to the physician.
The patient may be ashamed and unwilling to give a clear history of the assault, at precisely the time when such history is critical for timely treatment and forensic documentation. The need for both treatment and evidence collection means that clinicians find themselves simultaneously advocates for the patient and assistants to state and local law enforcement.
It is vital to both the health of the patient and the well-being of society that the ED physician know how to proceed in such cases.
Sexual assault is any sexual contact that is not consented and can happen through coercion or physical force.
It includes:
Forced rape
Alcohol- or drug-facilitated rape
Attempted rape and penetration, including oral, anal, and vaginal
Unwanted sexual contact or experiences
Forced sexual contact is an act of violence, not of sexual gratification.
A myriad of different psychological classifications have been proposed to characterize the sexual assailant, but the psychodynamics involved in all such schema involve feelings of inadequacy, unchanneled rage (eg, impulse control disorders), or other aberrant character disorders.[1]
The US Department of Justice 2016 Criminal Victimization reported 298,410 rape or sexual assault victimizations in the United States during that year.[2] Many more assaults occur than are reported due to postassault stress or concern of victim safety. It is estimated that 1 in 3 women and 1 in 6 men in the US had experienced some form of contact sexual violence during their lifetime and nearly 23 million women and 1.7 million men have been the victims of completed or attempted rape at some point in their life.[3]
In the course of a sexual assault, any injury may be inflicted on the victim, up to and including life-threatening multiorgan system trauma.
Posttraumatic stress disorder (PTSD) can cause long-term psychological impairment.[4] For further information, see Medscape's Resource Center on Posttraumatic Stress Disorder.
Unwanted pregnancy and sexually transmitted diseases (STDs), each stemming directly from the sexual nature of the attack, are also sources of subsequent morbidity and mortality.
There is a significantly higher prevalence of physical and mental health conditions, including asthma, irritable bowel syndrome, frequent headaches, chronic pain, difficulty sleeping, limitations in their activities, and poor mental health, reported in men and women with a history of sexual violence, physical violence, and/ or stalking by an intimate partner compared to women and men without a history of these forms of violence.[3]
Sexual assault victims come from all socioeconomic and racial groups.
Prevalence of women who reported lifetime contact sexual violence, physical violence, and/or stalking by an intimate partner by ethnicity is as follows:[5]
56.6% of multiracial women
47.5% of American Indian/Alaska Native women
45.1% of non-Hispanic Black women
37.3% of non-Hispanic White women
34.4% of Hispanic women
18.3% of Asian or Pacific Islander women
Data obtained from a Sexual Assault Nurse Examiner program was reviewed for all ED patient records with a complaint of sexual assault between January 1, 2000 and December 31, 2004. From this data, 1172 patient records were included; 92.6% were women; 59.1% were black, 38.6% were white, and 2.3% were classified as "other".[6]
Sex
Most sexual assaults involve women.[7] However, men may also present to EDs as victims of sexual assault. Societal attitudes and myths about male victims of sexual assault discourage them from coming forward; it is altogether likely that such assaults are even more underreported than female victim assaults.
Age
All ages are potential victims of sexual assault, from toddlers to elderly individuals. The majority of sexual assault victims are first victimized at a young age. Approximately 78.7% of female victims of completed rape were first raped before age 25 years, and 40.4% experienced rape before age 18 years.[5]
The 2015 national Youth Risk Behavior Survey administered by the Centers for Disease Control and Prevention assessed the risk of teen dating violence, both physical and sexual. The results show that, among high school students nationwide, nearly 16% of females reported sexual violence from a dating partner in the 12 months before they were surveyed and about 5% of males reported sexual violence from a dating partner.[8] Furthermore, 10.6% of students had been forced to do sexual things they did not want to do, including being physically forced to have sexual intercourse, by someone they were dating or going out with one or more times.[8]
A retrospective cohort analysis of 1917 adult women who had presented to either a sexual assault clinic or an ED found that 84% of the women were 18-39 years old while 4% of women were at least 50 years old.[9] Another study showed an average age of 27 years among women who presented to an ED.[6]
After performing a preliminary survey to establish the presence of any potentially serious injury or illness, obtain further history from the victim.[10] Address the following:
A brief description of the incident
Location of the assault
Identity of the assailant or assailants, if known
Home and workplace of the assailant, if known
Method by which the assailant left the scene
Whether or not a weapon was used to coerce the victim
Whether or not drugs were proffered to render the victim incapable of resistance
Whether or not the patient has changed clothes, showered, or douched since the incident
A standard obstetrics and gynecology (OB/GYN) history should also be taken to facilitate appropriate pregnancy and STD prophylaxis. This should include last menstrual period, birth control method, and time of last consensual intercourse.
In many jurisdictions, sexual assault centers provide trained examiners (generally Sexual Assault Nurse Examiners, or SANE teams) to perform evidence collection and to provide initial contact with the aftercare resources of the center. In such cases, the physician may confidently defer the gynecologic examination to the SANE; studies have repeatedly demonstrated the accuracy of sexual assault examinations performed by SANE teams. Clinicians must nonetheless be diligent and exacting in their general examination and in their documentation. Discrepancies between the ED record and the SANE report can sow doubt about the facts of the case in the minds of juries. Defense lawyers will not fail to exploit such discrepancies.
If no dedicated SANE teams or resources are available in the hospital's area, the assault examination falls to the ED physician.
Evidence of the use of force and/or lack of consent (eg, presence of blood and/or sperm, contusions, lacerations, other injuries consistent with resistance) should be sought.
Evidence of other injuries and diseases should be sought during the ED examination and treated where present. Again, the physical examination must be thorough and accurately documented.
Obtain urine or serum pregnancy tests in women of childbearing age.
Preexisting pregnancy may complicate management of coexisting injuries and is a contraindication to providing Ovral for pregnancy prevention.
Baseline screening for STDs includes the following:
Serologic tests for syphilis, hepatitis B, and HIV: HIV testing may be problematic in EDs because of laws in some states that stipulate mandatory counseling and follow-up care. However, the CDC recommends HIV screening for patients in all healthcare settings after the patient is notified that testing will be performed unless the patient declines (ie, opt-out screening).[11, 12] Policy and guidelines should be established in advance with local sexual assault aftercare groups and OB/GYN services in accordance with prevailing law and CDC guidelines.
Cultures of exposed body sites (eg, oral, throat, vaginal, rectal) as appropriate: Current Centers for Disease Control and Prevention (CDC) guidelines consider Food and Drug Administration (FDA)–approved nucleic acid amplification tests an acceptable substitute for culture, as long as positive test results are confirmed by a second study.[13] Other tests (EIA, nonamplified probes, direct fluorescent antibody tests) are not considered acceptable alternatives by the CDC because of unacceptable false-negative and false-positive result rates.
Wet mount and culture of a vaginal swab specimen to evaluate for Trichomonas vaginalis, bacterial vaginosis, and candidiasis
Recently, controversy has arisen concerning the usefulness of baseline STD testing of sexual assault victims. Opponents note the following:
Patients are offered antibiotic prophylaxis regardless of results from the preliminary screening.
The presence of STD baseline testing in the medical record invites defense attorneys to bring the victims to the witness stand, thereby opening prolonged interrogation of victims regarding their sexual histories in efforts to impeach the creditability of their stories. Many jurisdictions now forbid such inquiries into victims' personal lives, unless the victims' other sexual life experiences are somehow brought into the body of evidence before the court. These legal protections can, however, sometimes be breached, to the detriment of the victim.
These points are vigorously disputed by advocates of routine baseline testing. The CDC, in its most recent guidelines for the treatment and prevention of STDs, discusses the pros and cons of testing at some length.
To collect evidence, most hospitals have a prepackaged rape kit with the necessary equipment and detailed instructions. However, if the sexual assault victim presents 72 hours after the event, the evidence collection kit is no longer needed for legal documentation of the case.
Colposcopy, where available, may have considerable value in documentation because it allows photographic recording of injuries. Anoscopy may be performed in male victims, and it may be combined with colposcopy in female victims.
Evidence suggests that if speculum examination is performed before toluidine blue application to the posterior fourchette (to enhance small lesions that may occur during forceful genital penetration), the speculum itself may cause small lesions that will take up the dye. These iatrogenic lesions will be seen on colposcopy. Clinicians should consider deferring speculum examination until after external colposcopy if toluidine blue is to be used.
If EMS is involved in transporting the patient, their primary focus should be on stabilization of life-threatening injuries and providing emotional support for the victim. Evidence collection and crisis intervention should be handled by the ED team.
The responsibilities of the ED physician are more complex than in routine patients. The examiner must provide psychological support and referral to the appropriate resources, treat physical injuries, collect legal evidence, document pertinent history, perform a thorough head-to-toe physical examination, give prevention of unwanted pregnancy, and provide prevention of and screening for STDs.
Even in areas where SANE team support is readily available, the clinician must be mindful that the ED record also constitutes legal evidence. Treatment and documentation must be accurate and meticulous.
Common organisms of sexual assault STDs include: Chlamydia trachomatis, Neisseria gonorrhoea, Trichomonas spp., Hepatitis B, HIV, HPV, Tetanus
At present, guidelines for postsexual assault prophylaxis are as follows:[13, 14] [15]
Ceftriaxone 250 mg IM in a single dose, plus azithromycin 1 g PO in a single dose, plus metronidazole 2 g PO in a single dose or tinidazole 2 g PO in a single dose.
Evaluate the patient's hepatitis B immunization status. If victim is unvaccinated:
And perpretrator is known to be HBV infected: Administer Hep B vaccine series and HBIG preferrably within 24 hours of exposure. Follow up doses of HBV series at 1 and 6 months.
And perpretrator with unknown HBV status: Administer HBV vaccine series
Hepatitis B vaccine is not indicated if victim has been previously vaccinated and has documented immunity
Vaccination is recommended for female survivors aged 9–26 years and male survivors aged 9–21 years. For men who have sex with men (MSM) who have not received the HPV vaccine or who have been incompletely vaccinated, vaccine can be administered through age 26 years.[13, 14]
Administer a 2-dose vaccine (0, 6-12 months) schedule for girls and boys who initiate the vaccination series at ages 9 through 14 years. Three doses remain recommended for persons who initiate the vaccination series at ages 15 through 26 years and for immunocompromised persons (0, 1-2, 6 months).[16]
HIV postexposure prophylaxis (PEP) are individualized according to risk and must be started as soon as possible, and within 72 hours of exposure for HIV-uninfected persons.
A 28-day course of PEP is recommended: Tenofovir disoproxil fumarate (TDF) 300 mg PO daily and Emtricitabine 200 mg PO daily plus Raltegravir 400 mg PO twice daily or Dolutegravir 50 mg PO daily.[14]
Emergency contraception should be offered to female victims if the pregnancy test results are negative and initiated as soon as possible. The most effective options include:
Ulipristal 30 mg PO once within 120 hours; has highest oral efficacy.
Copper intrauterine device inserted within 120 hours. This is the most effective form of emergency contraception; however it is not done in the emergency department.
Levonorgestrel1.5 mg given as a single dose within 72 hours. [17]
Update tetanus status when necessary of the initial examination if they have not been previously vaccinated. If more than 5 years since last booster in tetanus-prone wound or more than 10 years in any wound:
Administer Tdap vaccine 0.5 ml IM
If less than 3 doses of primary vaccination series or status of victim is unknown and has a tetanus-prone wound
Adminitster Tdap vaccine 0.5 ml IM and tetanus immune globulin 250 units IM [15]
If available, offer a consultation with a sexual assault counselor in the ED. Further, refer the patient to a sexual assault center for aftercare and community resources. Given the long-term emotional and psychosocial impact of sexual assault on the victim, aftercare is vital. Community-based sexual assault centers are essential to such efforts; they serve not only as headquarters for SANE teams but also as aftercare clinics and resource centers for patients dealing with the aftermath of the assault. If such a center is not available, consultation with social services can provide access to such services that may exist in the region.
Refer to either the sexual assault center or the OB/GYN for follow-up on laboratory tests and to discuss subsequent HIV surveillance and completion of hepatitis B prophylaxis, when necessary. If the assailant is known to be HIV seropositive or is a high-risk contact, HIV prophylaxis should be considered at the time of ED contact if the patient is seen within the appropriate time window to initiate therapy. Immediate discussion with the OB/GYN and/or infectious diseases services is indicated in such cases. Risk of contracting HIV from an infected source via vaginal penetration is 8:10,000 and via anal penetration is 138:10,000.[14]
Guidelines on postexposure prophylaxis of the sexual assault victim are available from the CDC and New York State Department of Health.[14, 18]
Medical intervention in sexual assault is focused on prevention of unwanted pregnancy and STDs. The recommendations below follow the most recent CDC guidelines, dated 2015.[13]
Clinical Context:
Current DOC for prophylaxis against gonorrheal infection. Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Bactericidal activity results from inhibiting cell wall synthesis by binding to 1 or more penicillin-binding proteins. Exerts antimicrobial effect by interfering with synthesis of peptidoglycan, a major structural component of the bacterial cell wall. Bacteria eventually lyse because of the ongoing activity of cell wall autolytic enzymes while cell wall assembly is arrested.
Highly stable in presence of beta-lactamases and both penicillinase and cephalosporinase of gram-negative and gram-positive bacteria. Approximately 33-67% of dose is excreted unchanged in urine and remainder is secreted in bile and ultimately in feces as microbiologically inactive compounds. Reversibly binds to human plasma proteins and bindings have been reported to decrease from 95% bound at plasma concentrations < 25 mcg/mL to 85% bound at 300 mcg/mL.
Clinical Context:
In August 2012, the CDC announced changes to 2010 sexually transmitted disease guidelines for gonorrhea treatment. The Gonococcal Isolate Surveillance Project (GISP) described a decline in cefixime susceptibility among urethral N gonorrhoeae isolates in the United States during 2006-2011. Because of cefixime's lower susceptibility, new guidelines were issued that no longer recommend oral cephalosporins for first-line gonococcal infection treatment. Cefixime inhibits bacterial cell wall synthesis, and the bacteria eventually lyse because of ongoing activity of cell wall autolytic enzymes while cell wall assembly is arrested.
Clinical Context:
Active against various anaerobic bacteria and protozoa. Appears to be absorbed into cells. Intermediate-metabolized compounds formed bind DNA and inhibit protein synthesis, causing cell death.
Clinical Context:
Treats mild to moderate infections caused by susceptible strains of microorganisms. Indicated for prophylaxis of chlamydial infections of the genital tract.
Clinical Context:
Alternate to azithromycin in STD prophylaxis regimens. Broad-spectrum, synthetically derived bacteriostatic antibiotic in the tetracycline class. Almost completely absorbed, concentrates in bile, and is excreted in urine and feces as a biologically active metabolite in high concentrations.
Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. May block dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Clinical Context:
Levonorgestrel can prevent pregnancy through several mechanisms: thickening of cervical mucus, inhibiting sperm passage through the uterus and sperm survival; inhibition of ovulation, from a negative feedback mechanism on the hypothalamus, which reduces secretion of follicle stimulating hormone (FSH) and luteinizing hormone (LH); altering the endometrium, which may affect implantation.
These agents are used to prevent unwanted pregnancies after sexual assault. In addition to the contraceptive listed below, the intrauterine device (IUD) copper IUD may be used. Copper IUD is the most effective method of emergency contraception. Copper enhances the cytotoxic inflammatory response within the endometrium, impairs sperm migration and viability, and lowers the chances of survival of an embryo before it reaches the uterus. It can be removed after a woman's next menstrual period or left in place for up to 10 years as an ongoing contraceptive if desired.
Clinical Context:
A selective progesterone receptor modulator with primarily antiprogestin activity. It can delay ovulation and appears to be effective in the advanced follicular phase, including after LH levels have begun to rise but not peaked. It is most effective as an emergency contraception up to 120 hours after intercourse.
As noted above, aftercare is a vital component of recovery for the sexual assault victim. Every effort must be made to provide the victim with adequate referral to community resources.
Patients may be transferred to freestanding sexual assault clinics for evidence collection (when such centers exist); however, patients should be transferred only after coexistent trauma and disease have been assessed and treated.
Severe injuries may mandate transfer to regional trauma centers following surgical consultation.
In either case, compliance with Emergency Medical Treatment and Active Labor Act (EMTALA) requirements is mandatory.
Community education about sexual violence is generally agreed to be worthwhile, although evidence for its efficacy in incident reduction is meager, at best.
For excellent patient education resources, see eMedicineHealth's patient education article Sexual Assault.
Marian Sackey, MD, Resident Physician, Department of Emergency Medicine, Louisiana State University School of Medicine in New Orleans
Disclosure: Nothing to disclose.
Coauthor(s)
Heather Murphy-Lavoie, MD, FAAEM, FACEP, Associate Professor, Assistant Residency Director, Emergency Medicine Residency, Associate Program Director, Undersea and Hyperbaric Medicine Fellowship, Section of Emergency Medicine, Louisiana State University School of Medicine in New Orleans; Clinical Instructor, Department of Surgery, Tulane University School of Medicine
Disclosure: Nothing to disclose.
Specialty Editors
Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Robert Harwood, MD, MPH, FACEP, FAAEM, Senior Physcian, Department of Emergency Medicine, Advocate Christ Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago College of Medicine
Disclosure: Nothing to disclose.
Chief Editor
Gil Z Shlamovitz, MD, FACEP, FAMIA, Professor of Clinical Emergency Medicine, Keck School of Medicine of the University of Southern California; Chief Medical Information Officer, Keck Medicine of USC
Disclosure: Nothing to disclose.
Additional Contributors
Francis Counselman, MD, FACEP, Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School
Disclosure: Nothing to disclose.
William S Ernoehazy, Jr, MD, FACEP, Attending Physician, Department of Emergency Medicine, Flagler Hospital; Attending Physician, Baptist Emergency at Town Center
Disclosure: Nothing to disclose.
Acknowledgements
The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous editor, Charles V Pollack Jr, MD, to the development and writing of this article.
Morgan, Rachel E. and Grace Kena. Criminal Victimization, 2016: Revised. Bureau of Justice Statistics. October 2018. Available at https://www.bjs.gov/content/pub/pdf/cv16re.pdf
Smith, S.G., Chen, J., Basile, K.C., et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010-2012 State Report. National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention. 2017. Available at https://www.cdc.gov/violenceprevention/pdf/NISVS-StateReportBook.pdf
[Guideline] Dominguez, Kenneth L. ; Smith, Dawn K; Vasavi Thomas et. al. Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV—United States, 2016. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/std/tg2015/default.htm. 2016 Apr 18; Accessed: November 9, 2018.
[Guideline] Christiana Care Health System. GU: Sexual Assault STD Prophylaxis. Levine, Brian J. EMRA Antibiotic Guide. 17th. Irving, TX: EMRA; 2017. 50-51.
Meites E, Kempe A, Markowitz LE. Use of a 2-Dose Schedule for Human Papillomavirus Vaccination — Updated Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2016. 65:1405-1508.
[Guideline] New York State Department of Health Aids Institute. HIV prophylaxis for victims of sexual assault. HIV Clinical Resource. Available at http://www.hivguidelines.org/wp-content/uploads/2014/10/hiv-prophylaxis-for-victims-of-sexual-assault.pdfxis-following-non-occupational-exposure.pdf. October 28, 2014; Accessed: November 10, 2015.
Office on Violence Against Women. National Protocol for Sexual Assault Medical Forensic Examinations (Adults/Adolescents), 2nd ed. US Dept of Justice. Apr 2013. Available at https://www.ncjrs.gov/pdffiles1/ovw/241903.pdf. Accessed: May 8 2013.
Herman AO. Updated Guidelines Issued for Medical Exams in Cases of Sexual Assault. Physician’s First Watch. Apr 26 2013. Available at http://firstwatch.jwatch.org/cgi/content/full/2013/426/1. Accessed: May 8 2013.
US Dept of Justice. Justice Department Releases Updated Protocol To Improve Standards for Responding to Rape and Sexual Assault. Apr 24 2013. Available at http://www.justice.gov/opa/pr/2013/April/13-ag-466.html. Accessed: May 8 2013.
Braun GR. Sexual assault. Emergency Medicine: Concepts and Clinical Practice. 3rd ed. St. Louis: Mosby-Year Book; 1992. 2003-12.
Higgins SD, Schwartz GR. The sexually assaulted patient. Sexual assault evidence collection protocol, Office of the Attorney General. Principles and Practice of Emergency Medicine. 3rd ed. Williams & Wilkins; 1992. 2418-31.
Littel, K. Sexual Assault Nurse Examiner (SANE) Programs: Improving the Community Response to Sexual Assault Victims. US Department of Justice, Office of Justice Programs, Office for Victims of Crime. April 2001. Available at http://www.ojp.usdoj.gov/ovc/publications/bulletins/sane_4_2001/welcome.html
Rand M, Catalano S. Criminal Victimization, 2006. U.S. Department of Justice, Bureau of Justice Statistics. Dec 2007. Available at http://www.ojp.usdoj.gov/bjs/abstract/cv06.htm
