Practice Essentials
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:
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Presence of blood and/or sperm
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Contusions
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Lacerations
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Abdominal trauma
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Joint dislocation
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Mechanical back pain
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Abruptio placentae
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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:
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Serologic tests for syphilis, hepatitis B, and HIV
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Cultures of exposed body sites, as appropriate, to evaluate for STDs (eg, oral, throat, vaginal, and rectal)
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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.
See Treatment and Medication for more detail.
Background
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.
Pathophysiology
Sexual assault is any sexual contact that is not consented and can happen through coercion or physical force.
It includes:
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Forced rape
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Alcohol- or drug-facilitated rape
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Attempted rape and penetration, including oral, anal, and vaginal
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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]
Frequency
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]
Mortality/Morbidity
In the course of a sexual assault, any injury may be inflicted on the victim, up to and including life-threatening multiorgan system trauma.
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Posttraumatic stress disorder (PTSD) can cause long-term psychological impairment. [4] For further information, see Medscape's Resource Center on Posttraumatic Stress Disorder.
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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.
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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]
Epidemiology
Race/Ethnicity
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]
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56.6% of multiracial women
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47.5% of American Indian/Alaska Native women
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45.1% of non-Hispanic Black women
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37.3% of non-Hispanic White women
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34.4% of Hispanic women
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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]
