Version May 2024
INTRODUCTION — Sexual violence is an all-encompassing term including all sexual acts attempted or completed by another person without freely given consent of the victim or against someone who is unable to consent or refuse [1]. Sexual assault is defined as any deliberate sexual act performed by one person on another without explicit consent. The Federal Bureau of Investigation (FBI) defines sexual assault as “penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim” [2]. It may result from the use of force, the threat of force, or from the victim's inability to give consent. Sexual assault is an act of conquest and control. Sexual assault is never the victim’s fault. Sexual assault victims are at increased risk for developing posttraumatic stress disorder (PTSD) along with chronic medical conditions.
The emergency department evaluation and treatment of adult and older adolescent victims of sexual assault are discussed here. The discussion is based on practice in the United States, but the general principles are applicable worldwide. Caring for child victims of sexual assault, the outpatient evaluation and management of date rape, screening and intervention for intimate partner violence, and general trauma evaluation and management are all reviewed separately:
●(See "Management and sequelae of sexual abuse in children and adolescents".)
●(See "Evaluation of sexual abuse in children and adolescents".)
●(See "Date rape: Identification and management".)
●(See "Date rape: Risk factors and prevention".)
●(See "Adolescent relationship abuse including physical and sexual teen dating violence".)
●(See "Intimate partner violence: Diagnosis and screening".)
●(See "Intimate partner violence: Intervention and patient management".)
●(See "Initial management of trauma in adults".)
EPIDEMIOLOGY — The National Intimate Partner and Sexual Violence Survey administered in the United States by the Centers for Disease Control and Prevention (CDC) in 2016/2017 found that 27 percent of females and 2 percent of males reported completed or attempted rape victimization at some point in their lifetime. Over the 12 months preceding the survey, 2 percent of females and less than 1 percent of males reported victimization [3]. LGBTQI+ people, females, ethnic and racial minorities, and those with disabilities are disproportionally affected by acts of sexual violence. More than 80 percent of sexual assault victims report having been raped prior to 25 years of age, and more than 50 percent of victims report that the perpetrator was an acquaintance. Sexual violence against females is common throughout the world [4].
Many cases of sexual assault involve ethanol or illicit agents [5-7]. In one series, almost 30 percent of female undergraduates reported a drug-related assault, with ethanol as the most common substance involved [5,6]. Two-thirds of older females are assaulted in their own homes or in care facilities [8]. In males, the prevalence of assault appears to be higher among those who are gay, bisexual, veterans, prison inmates, and those seeking mental health services [9].
Rape is under-reported [3]. Reported sexual assaults represent only a fraction of those committed. Only 10 to 15 percent of all sexual assaults are reported to police, and females who know their assailant are less likely to report the assault [10].
Immigrants and undocumented people may be particularly vulnerable to sexual assault and face added barriers to obtaining care. They often have language barriers, are not familiar with legal and medical resources, do not have access to medical providers, may fear the legal system, and may have memories of prior victimization [11].
Epidemiology of LGBTQI+ people is covered separately:
PROVIDER PREPAREDNESS — A national protocol for sexual assault medical forensic evaluations of adults and adolescents is available online through the United States Department of Justice, Office of Violence Against Women [12].
Providers should learn about local and hospital resources for sexual assault victims before they are asked to care for a sexual assault victim. The following issues should be researched:
●Who are the available sexual assault nurse examiners (SANEs) or other trained providers in the community? How can they be contacted? Does the hospital contract with a SANE provider, or will the emergency clinician perform the evidence collection themselves? Can the patient be transferred to a hospital with trained forensic providers?
●Are there cultural issues for members of the community that might require special adaptation for the evaluation of sexual assault? Are interpreters available?
●What are the local requirements for collection of evidence and for documentation? Evidence collection kits and forensic documentation forms should be available immediately when a patient presents needing evaluation.
●Is there an ultraviolet light source? Is an appropriate camera available? Is colposcopy available?
●What are the local requirements for toxicology screening for agents utilized in drug-facilitated sexual assault?
●What are the jurisdictional policies regarding mandatory reporting? (See 'Legal issues' below.)
●What is the local contact for sexual assault crisis support services?
●What are the appropriate screening and treatment protocols?
●Can the registration process and/or electronic tracking system not publicly display the patient's name and restrict access to the medical record to ensure safety and protect privacy?
EVALUATION
Overview — The assessment of sexual assault victims includes several domains [13-16]:
●Assessment and treatment of physical injury with special focus on the genitalia
●Psychological assessment and support
●Pregnancy assessment and prevention
●Evaluation, treatment, and prevention of sexually transmitted infections (STIs)
●Forensic evaluation
●Assessment of safety prior to discharge
After medical clearance has been provided by the emergency clinician, when possible, the complete evaluation should be done by providers specifically trained to care for victims of sexual assault (eg, sexual assault nurse examiner [SANE]/sexual assault forensic examiner [SAFE]). Others may do this evaluation in the following circumstances:
●A trained provider is not available.
●The patient prefers that the examination be done by another provider, understanding a biased or inadequate evaluation may affect the likelihood of identification and prosecution of the perpetrator. Bias may be presumed if the provider is a friend or personal physician to the victim.
●The evaluation is occurring later than the locally determined interval for formal evidence collection, which can be up to five to seven days depending upon jurisdiction policy. (See 'Forensic evaluation' below.)
Complete evaluations are time intensive and may require three to six hours. Proper evaluation requires maintenance of the chain of custody of evidentiary material. Examiners should anticipate that they may be called to testify in court if a case is prosecuted. Patients must be counseled about each component of the evaluation and documentation. They may choose to decline individual components but must first be counseled on the purpose of those components and the possible impact of their choices on health and prosecution outcomes.
Requirements for the forensic evaluation will vary by jurisdiction, and it is important for the provider performing the evaluation to know local requirements.
Trained providers — Many institutions in the United States have established SANE models or related programs for acute care [12,16,17]. The International Association of Forensic Nurses (IAFN) is a source of information on programs in other countries [18]. Some programs train a broader range of clinicians including physicians, physician assistants, and advanced practice providers who might then be referred to as SAFE.
SANE programs are supported at the federal level in the United States by the Department of Justice, Office of Victims of Crime. The United States Department of Justice has established training standards [19]. State-specific information is available at centers.rainn.org.
These trained providers:
●Expedite evaluation
●Improve the consistency and quality of collected forensic evidence and ensure adherence to specific protocols regarding evidence collection and maintenance of the legal "chain of evidence" (see the National Institute of Justice website)
●Coordinate state crime lab testing, if appropriate, including assessment for common "date rape" drugs (eg, benzodiazepines, antipsychotics, diphenhydramine, flunitrazepam [Rohypnol], gamma hydroxybutyrate [GHB]) when appropriate
●Increase success of criminal prosecution and provide a bridge between the medical and criminal justice systems
●Link the victim with community services (including Rape Crisis Centers)
●Improve sensitivity to the psychological trauma experienced by sexual assault victims
●Evaluate the patient after the clinician provides "medical clearance" (ie, medical issues and injuries have been addressed and stabilized)
●Potentially enhance communication with clinicians regarding patient questions or concerns
History and documentation — A trauma-informed care approach should be utilized in all cases with an understanding of the impact and symptoms of trauma (table 1). Histories must be obtained in a sensitive and supportive manner, and care should be taken to avoid asking questions in a leading manner. Providers should not force evaluation or treatment and should allow the victim control in the evaluation process. A chaperone or advocate should be present during the evaluation. Advocates present during the exam can support patients and help them articulate their needs and questions during the history, but advocates should not respond to questions [12].
In a patient who is medically cleared and will undergo SANE or SAFE evaluation, the clinician should obtain the history and document in the medical chart the reported events that relate to injuries being evaluated. This history guides trauma assessment and assesses risk of pregnancy and STIs. The clinician does not need to elaborate on a detailed forensic history (unless it pertains to the medical evaluation) since this will be recorded on a separate form by the SANE or SAFE. The clinician providing medical clearance does not need to obtain a full forensic history, if at all feasible, as it may re-traumatize the patient.
Some states require specific forms for documenting history and examination. Keeping the sexual assault report separate from the medical record is customary and has a precedent in psychiatric records. A “break the glass” requirement is often utilized for computerized records to prevent unwarranted views. Patients may request records, but SANE or SAFE is usually involved in release for counseling and support purposes.
Terms that are suitable for the medical chart, final diagnosis, and discharge instructions include the following:
●Perpetrator evaluation
●Sexual assault
●Evaluation following sexual assault
●Assault
Term to avoid include the following:
●Alleged sexual assault
●Rule out sexual assault
●Reported sexual assault
Other identified injuries (eg, fractures, closed head injury, contusions) and diagnoses should also be listed.
If SANE/SAFE are unavailable at the hospital, the clinician is responsible for documenting the detailed forensic history on the evidentiary form. This history focuses on a detailed and precise account of the sexual assault in the event of prosecution. The following should be obtained as part of the forensic history:
●Circumstances of the assault (including date, time, location, and use of weapons, force, restraints, or threats).
●Whether or not the victim experienced loss of consciousness or memory loss.
●The assailant's physical description along with the assailant's use of drugs or alcohol.
●Specifics regarding kissing, licking, and oral, vaginal, or anorectal contact or penetration with presence or absence of ejaculation and/or condom use.
●Areas of trauma should be ascertained focusing especially upon the victim's mouth, breasts, vagina, and rectum.
●Bleeding of either assailant or victim may be relevant in assessing the risk of hepatitis or human immunodeficiency virus (HIV) transmission. The source of genital bleeding should be ascertained, especially since some injuries can cause life-threatening large-volume bleeding.
●Recent consensual sexual activity before or after the assault including details about site of contact (oral, genital, anorectal) and condom use.
●After the assault, any wiping, showering, bathing, changing clothes, eating, using toothpaste or mouthwash, using enemas, or changing/removing a tampon, sanitary pad, or barrier contraceptive device can lower the yield of forensic specimen collection. However, patients should not be reprimanded for taking any of these actions.
Physical examination — The physical examination should focus on identifying and documenting evidence of trauma. Suggested terminology for describing examination findings includes the TEARS mnemonic: tears (defined as any break in tissue, including fissures and lacerations), ecchymoses, abrasions, redness, and swelling [20]. The physical examination should also describe the patient's mental status. Physical examination evidence of trauma is more likely to be present within 72 hours of assault and when assaults occurred outdoors or were perpetrated by strangers [21]. Examine the patient in a forensic suite or dedicated room where the patient feels safe and there is adequate privacy without interruptions. Use gloves during the examination and evidence collection to avoid cross-contamination of evidence and change gloves in between each step of evidence collection.
●The patient should undress for the examination with a sheet beneath them to capture any falling debris for medical evidence. The patient should then be given a gown, socks, and warm blankets for comfort.
●Life-threatening genital injury (eg, vaginal hemorrhage) needs to be urgently evaluated and addressed by the clinician. The examination and care should not be delayed for the forensic evaluation (ie, SANE).
●If possible and the patient provides consent, photographs of injuries should be taken with hospital-certified equipment (eg, digital camera, colposcopy camera). A ruler or an easily identified object is helpful for indicating the size of objects in photographs. Photographs should be taken at 90 degrees to the finding and include full view of the person with the finding followed by closer views. All photographs should be saved.
●Extragenital trauma is often more common than anogenital trauma (70 versus 27 percent), with bruises, abrasions, or erythema on the thigh, upper arm, face, or neck particularly common [22].
●In females, the breasts, external genitalia, vagina, perineum, anus, and rectum should be carefully examined. Common sites of genital injury include the posterior fourchette and the labia minora. As compared with females who have had consensual sex, females who have been assaulted are more likely to have genital injury at sites other than the posterior fourchette and are more likely to have multiple injured areas [23]. Genital trauma occurs more commonly in postmenopausal and adolescent females [10,24], and detectable trauma is more likely in females reporting vaginal or anal penetration along with those who have not previously been sexually active [25].
●Colposcopic examination can enhance detection of areas of subtle genital trauma and is now performed by most SANE programs [26,27]. A Wood's lamp or alternative ultraviolet light source may help identify foreign debris and semen on the skin; however, these light sources are not very specific, and false positive results may occur from common creams, detergents, and other products. Evidence of anogenital trauma is enhanced with colposcopy or use of toluidine blue dye, which adheres to injured nuclei in damaged epithelial cells, but can be difficult to use, challenging to recognize on darker skin, and not endorsed in all United States jurisdictions.
●In male victims, closely examine the thighs, penis, glans, urethral meatus, scrotum, and perineum, evaluating for erythema, scars, ecchymosis, excoriation, or laceration [28]. Penile examination should focus particularly on the glans and frenulum and should assess for urethral discharge. Rectal examination should be considered and performed if there was anal penetration. Anal injury was documented in 14 percent of those consenting to examination in an Australian center [29].
Forensic evaluation — Forensic evaluation should be offered to victims but is not mandatory. Forensic evaluation involves collection of numerous specimens in a meticulous fashion. In the United States, the Violence Against Women Act (VAWA) ensures patients are not required to pay for the forensic services. (See 'Legal issues' below.)
●Informed consent – Forensic evaluation requires informed consent from the patient. Specific forensic consent forms should be included in evidence collection kits. Patients will need to consent to the examination, collection of evidence, and forensic photography and decide if they want to report to law enforcement or not. The forensic examiner should only proceed if the patient has a thorough understanding of the exam. The patient has the right to refuse any part of the exam at any time while allowing other parts to proceed.
●Option for delayed law enforcement involvement – Many jurisdictions have policies that allow the patient to have evidence collected and stored, leaving the patient the option to report to law enforcement at a later date. The VAWA program creates and supports comprehensive, cost-effective responses to sexual assault by allowing for the sexual assault examination to occur without requiring law enforcement involvement.
●Patients who cannot provide consent – Performing a forensic evaluation in a suspected sexual assault victim who is unable to provide consent is controversial. A previously identified guardian would be authorized to provide consent. In the absence of a guardian or surrogate decision-maker, portions of the examination might be done if routine examination already requires examination of those areas, would not induce additional discomfort, and/or if a medical procedure is to be done that would destroy evidence [30]. It is important to involve a hospital ethics and legal team if needed.
Components of the examination that require sedation should not be done, and photographs of intimate areas should not be taken without consent. Materials obtained prior to consent would only be released to law enforcement when consent is obtained at a later time.
●Evidence collection kits – Evidence is collected using jurisdictionally specific sexual assault evidence kits or physical evidence recovery kits, which are sometimes referred to as “rape kits.” These kits contain all the necessary supplies to collect and store evidence and can be obtained through state distribution programs or directly from kit manufacturers. There are a variety of commercial collection kits available, but states often require specific kits. Check the kit’s expiration of use date prior to initiating the collection.
Kits contain specific collection materials that are distinct to each specimen obtained and precise collection instructions. It is important to carefully follow collection guidelines to avoid contamination. Gloves should be changed in between each step of the evidence collection. Swabbed specimens may need to be dried; some jurisdictions mandate specific drying techniques. If a piece of evidence is wet when collected, the package should be labeled as such, and the police or crime laboratory be made aware so that they can dry and repackage the evidence. When completed, kits must be sealed, labeled, and stored using kit-specific directions to maintain an unbroken chain of evidence. Collected samples include:
•The victim's clothing.
•If the patient is brought by ambulance from the site of the assault, any sheets used to transport the patient and any debris on them should be kept [13].
•Swabs and smears from the buccal mucosa, vagina, and rectum and from other areas (that were licked, kissed, touched, or bitten) highlighted by ultraviolet light.
•Combed specimens from the scalp and pubic hair. Given the painful and invasive nature of plucking hairs, many jurisdictions no longer require hair samples. We recommend avoiding this painful step. If it is performed, obtain control samples of the victim's scalp and pubic hair (20 to 25 pulled hairs per site).
•Fingernail scrapings and clippings.
•Whole blood sample.
•Saliva sample.
●Timing of evidence collection – The yield of evidentiary examinations generally declines with time and with specific behaviors like changing clothes, showering, and brushing teeth. In general, there may be only one opportunity to collect evidence, so when in doubt, it is best to obtain it.
Individual jurisdictions determine the maximal time interval during which certain evidence may be collected; intervals vary depending upon patient history, hygiene, and the specimen being obtained. Many jurisdictions use a five- or seven-day evidentiary cutoff [31,32]. Historically, jurisdictions limited evidence collection to the first 72 hours after assault. However, there is no absolute interval during which evidence must be obtained, and as DNA technologies develop, the time available for evidence collection may expand [12].
As examples, swabs from external skin would not be useful in a victim who presents over 24 hours after an assault and has showered in the interim, but cervical and vaginal swabs, and possibly fingernail scrapings, would still be valuable. In cases of oral and anal assault, evidence is usually not collected beyond 24 hours after the assault. In cases of vaginal assault, DNA may be collected up to five days after the assault. Sperm has been detected in vaginal samples up to 72 hours after assault and in anal samples up to 24 hours after assault; sperm are not generally detectable in oral samples [22].
Perpetrator evaluation — Clinicians may occasionally be asked to perform a forensic evaluation of an assault perpetrator [33]. This exam is often critical for the forensic investigation, and the same meticulous approach to patient evaluation should be utilized. Principles for evidentiary examinations are similar to those for victims and require evidence collection kits and maintaining the chain of evidence. All historical information that the suspect offers should be recorded, but the suspect has the right to not provide any incriminating history. Swabs, hair combing, and fingernail sampling are obtained. Finger swabs would be done in cases of digital penetration of a victim [34]. In males, penile swabs should be collected from the shaft, glans, and area under the foreskin. Bruises, scratches, and bite marks are identified, with swabbing of bites and scratches to identify victim DNA. Blood samples for HIV and hepatitis B can be drawn and held; in many jurisdictions, victims can ask the court to have the suspect tested.
Physical examination evidence of trauma is most common on the hands, forearms, face, and neck [22]. Permanent physical attributes, such as tattoos, are described. If victim and assailant are in the same facility, they should be evaluated in physically separate settings by different personnel to avoid any accusation of cross-contamination of specimens.
The perpetrator will often comply with the examination, but if the perpetrator refuses the evaluation or parts of the evaluation, the clinician cannot force it upon them unless law enforcement has a valid search warrant/court order or incident to an arrest to preserve evidence. If a clinician is uncomfortable examining a perpetrator who refuses, we suggest speaking to their hospital legal team for guidance [35].
Laboratory testing and diagnostic imaging — Laboratory evaluation is focused on testing for STIs and pregnancy. Radiographic imaging is guided by the history and physical examination along with a focused trauma assessment, which should be performed prior to providing clearance for the forensic evaluation. (See "Initial management of trauma in adults", section on 'Diagnostic studies'.)
Testing for STIs has been considered elective, as guidelines recommend empiric treatment for possibly acquired STIs, and testing does not provide clear evidence of infection acquired at the time of assault. Victims may forego testing if they plan to take prophylactic treatment for STIs, which will also treat any pre-existing STI [36].
Historically, there has been concern that a positive STI test might be used by the defense as evidence of promiscuity to discredit the victim since any identified STI is likely to be pre-existing. However, many states limit the evidentiary use of a victim's prior sexual history [37]. Although this rarely occurs, evidence of a STI obtained at the time of the evaluation for assault could be accessed later, and some patients or clinicians may choose to defer testing for this reason despite these "rape shield" laws.
●We perform gonorrhea and chlamydia nucleic acid amplification testing (NAAT) in an adult patient who complains of signs or symptoms of an STI, specifically requests testing, or initially declines prophylaxis (to ensure appropriate therapy is eventually provided) and in a child (since the presence of an STI can be conclusive proof of a sexual assault). (See "Screening for sexually transmitted infections", section on 'Chlamydia and gonorrhea' and "Vaginitis in adults: Initial evaluation".)
●We perform serum testing for HIV, hepatitis B, and syphilis. Although there are reports of sexual transmission of hepatitis C, there are no known reports of transmission associated with sexual assault, and testing for hepatitis C is not addressed in current Centers for Disease Control and Prevention (CDC) recommendations. Given the relatively low risk and the absence of protocols for prophylaxis against hepatitis C, most programs have not incorporated hepatitis C testing into the evaluation of sexual assault, and we believe this is reasonable. (See "Screening and diagnostic testing for HIV infection" and "Hepatitis B virus: Screening and diagnosis in adults" and "Syphilis: Screening and diagnostic testing".)
●Wet preps may show motile sperm; jurisdictions vary as to whether the examiner or the forensic laboratory is to make that evaluation.
●Pregnancy testing should be performed in females of childbearing age. (See "Clinical manifestations and diagnosis of early pregnancy", section on 'Diagnosis'.)
●We perform selective drug screening since clinical and forensic testing requires distinct samples, assays, and laboratories. Forensic drug testing may be warranted if the victim has amnesia for any time surrounding the event, manifests suggestive signs or symptoms (eg, sedation), or suspects that they were drugged. Alcohol may be the most common date rape drug; benzodiazepines and other sedatives may also be implicated [22]. Patients should understand that drug testing may also reveal voluntary drug or alcohol use that potentially can be used by the defense to discredit victims [12]. (See "Ethanol intoxication in adults" and "Benzodiazepine poisoning" and "Gamma hydroxybutyrate (GHB) intoxication".)
Samples obtained for forensic purposes should be analyzed by forensic laboratories rather than the clinical laboratory of the examining facility. For example, forensic testing for flunitrazepam (ie, Rohypnol, the "date rape drug") and GHB is not offered by most hospital laboratories and has a long turnaround time, so this is typically unhelpful in clinical management. Clinically available hospital drug of abuse screens are immunoassays that test for exposure and not intoxication and have poor sensitivity and specificity for most intoxicants; therefore, they must be interpreted with these limitations. (See "Testing for drugs of abuse (DOAs)".)
Blood and urine samples are generally required and should be obtained following instructions from the evidence collection kit; timing of collection of urine samples may be critical for maximal detection. Most samples will remain with the evidence collection kit, but if the samples are separate from the kit, make sure to maintain a chain of custody.
MANAGEMENT
Overview — Initial management of the sexual assault victim focuses on addressing injuries, such as fractures, soft tissue injuries, anogenital injuries, and possibly strangulation. A strangulation attempt with loss of consciousness, bowel and bladder incontinence, persistent voice changes, difficulty swallowing, or shortness of breath should be comprehensively evaluated in the emergency department with imaging as indicated. In one series, hospital admission was required more often in older females, with 16 percent of females older than 55 years hospitalized [10]. (See "Initial management of trauma in adults" and "Blunt cerebrovascular injury: Mechanisms, screening, and diagnostic evaluation".)
After injuries have been identified and addressed, treatment should focus on prophylaxing against sexually transmitted infections (STIs; including gonorrhea, chlamydia, hepatitis B, and HIV) and tetanus, preventing pregnancy, and managing psychosocial issues [13-15]. (See 'Psychosocial issues' below.)
Sexually transmitted infection post-exposure prophylaxis
Gonorrhea, chlamydia, and trichomoniasis — The Centers for Disease Control and Prevention (CDC) and others recommend empiric antibiotic treatment since many assault victims will not return for a follow-up visit [37-39]. In addition, patients often prefer immediate treatment. Empiric therapy includes the following:
●Ceftriaxone 500 mg by intramuscular injection to treat gonorrhea. Administer ceftriaxone 1 g intramuscularly in a patient weighing >150 kg. (See "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents", section on 'Initial treatment of urogenital infection'.)
●Doxycycline 100 mg by mouth twice daily for seven days to treat chlamydia. Doxycycline is preferred over azithromycin because of superior microbial efficacy, but for individuals who are unlikely to be able to complete the seven-day doxycycline course (eg, those for whom adherence may be a concern), a single oral dose of azithromycin 1 g is an alternative. (See "Treatment of Chlamydia trachomatis infection", section on 'Antibiotic regimens in adults and adolescents'.)
●Metronidazole 500 mg by mouth twice daily for seven days to empirically treat trichomoniasis (empiric treatment in males is not recommended). Treatment with a single 2 g oral dose of either metronidazole or tinidazole is associated with lower rates of cure compared with metronidazole multidose therapy, and we reserve single-dose therapy for those who are unable to complete the full treatment course. Specific instructions to avoid alcohol with metronidazole should be provided. (See "Trichomoniasis: Treatment", section on 'Females'.)
Prophylaxis against herpes simplex infection and syphilis is not recommended.
Patients who decline empiric treatment should be seen one week after the initial evaluation to determine the need for treatment based on initial testing and for repeat testing if needed. (See "Screening for sexually transmitted infections".)
The risk of acquiring an STI is difficult to measure due to inadequate follow-up in many studies, and an infection transmitted during an assault may be detected during the baseline evaluation if performed days after the event. One French study of 326 adult and adolescent sexual assault victims reported that polymerase chain reaction (PCR) detected chlamydia in 15 percent and gonorrhea in 5 percent of patients presenting for evaluation but did not provide information about the duration of time between the assault and medical evaluation [40]. Another study performed in Norway found that 6 percent of patients were positive for chlamydia at the time of assault [41].
Hepatitis B infection — The need for prophylactic treatment against hepatitis B virus (HBV) infection with either vaccine or hepatitis B immune globulin (HBIG) depends upon the patient’s vaccination and immune status, the nature of the exposure, and the HBV status of the assailant [36,37]. A table and algorithm summarizing postexposure prophylaxis against HBV is provided (table 2 and algorithm 1) and summarized below, and prophylaxis is discussed in detail separately (see "Management of nonoccupational exposures to HIV and hepatitis B and C in adults", section on 'Exposure to hepatitis B virus'):
●A previously vaccinated person with immunity against HBV (previously documented serum anti-HBs antibody ≥10 milli-international units/mL) or who has previously been infected with HBV is immune to reinfection and does not require post-exposure prophylaxis.
●Those who received a hepatitis B vaccine as children likely would not have been tested for immunity; we suggest previously vaccinated patients not known to be immune receive a single hepatitis B booster vaccination.
●If the exposed patient is uncertain if they completed the hepatitis B vaccine series, they should be treated as if they are unvaccinated and complete the series. Follow-up doses of hepatitis B vaccine should be administered to complete the vaccine series.
●In addition to vaccination, administer HBIG if the HBV status of the assailant is positive or unknown and the patient is unvaccinated or nonimmune, vaccination status is unknown, or the patient has no history of HBV infection.
HIV infection — Prophylactic treatment with antiretroviral drugs for HIV following sexual assault should be addressed with every patient. Despite the presumed low risk of transmission (table 3) and the lack of evidence proving the efficacy of antiretroviral drugs after sexual assault, many organizations and infectious disease specialists believe that they should be offered.
Antiretroviral medications are best started within four hours of assault and are not recommended if more than 72 hours has passed [42]. Options for prophylactic regimens are described separately. (See "Management of nonoccupational exposures to HIV and hepatitis B and C in adults", section on 'Antiviral therapy'.)
The CDC recommends that patients who decide to take post-exposure prophylaxis be given either an initial supply of post-exposure prophylaxis for three to seven days (starter pack) or the supply needed for an entire treatment course (28 days). In either case, short-term follow-up for further counseling is strongly recommended and would be required to complete treatment for those given only a starter pack [43]. Compliance with treatment may be low; a meta-analysis that included 26 studies involving more than 3000 victims of assault found that only 40 percent of patients completed prophylaxis [44].
There are no good data on the risk of acquiring HIV from an unknown assailant, although there are case reports of HIV transmission after sexual assault [42]. The risk of HIV transmission from a single episode of consensual vaginal intercourse with an HIV-infected male is estimated at 0.1 percent, and from a single episode of consensual anal intercourse at 2 percent. The risk of transmission after sexual assault by an HIV-infected male is likely to be higher since there may be associated trauma and bleeding [45]. (See "HIV infection: Risk factors and prevention strategies", section on 'Risk factors for infection'.)
While the overall risk of acquiring HIV after an assault by an unknown assailant is likely low, the risk may be increased by certain aspects of the assault:
●Male-to-male rapists might be expected to have a higher prevalence of HIV infection.
●Sexual assault in a region or country with a high background prevalence of HIV increases the likelihood that an assailant will be HIV infected. Country-specific data can be found at http://www.unaids.org/en/regionscountries/countries.
●Multiple assailants presumably increase the risk since any of the assailants might be infected with HIV.
●Anal sexual assault may be more likely to transmit HIV.
●Sexual assault where either the assailant or the victim has trauma, bleeding, or genital lesions may increase the likelihood of transmission.
Human papillomavirus infection — Human papillomavirus (HPV) vaccination is suggested at the time of initial evaluation after sexual assault in female survivors aged 9 to 26 and male survivors aged 9 to 21 as recommended in the CDC guidelines [37]. Follow-up vaccination to complete the series is recommended at one to two months and six months after initial vaccination. (See "Human papillomavirus vaccination".)
Preventing pregnancy — Postcoital emergency contraception (EC) should be offered to all persons capable of pregnancy [16]. In general, EC options include two intrauterine devices (IUDs) and several oral medications (table 4). While confirmed pregnancy is the only absolute contraindication to EC use, EC does not cause abortion. An algorithm for selection of EC is presented (algorithm 2); choices are summarized below and discussed in detail elsewhere (see "Emergency contraception"):
●Oral medication – Oral medications for EC are simple to administer but are less effective at preventing pregnancy than an IUD. They also may be less effective in patients with overweight or obesity compared with normal-weight patients (table 4). (See "Emergency contraception", section on 'Oral medication emergency contraception methods'.)
•Ulipristal acetate – Ulipristal acetate, 30 mg given once, is the most effective oral medication, can be given up to 120 hours (five days) after exposure, and appears to have similar efficacy for overweight individuals (body mass index 25 to <30). It is less effective in patients with a body mass index >30.
•Levonorgestrel – Levonorgestrel (0.75 mg and repeated in 12 hours, or 1.5 mg as a single dose) is available over the counter in many countries. While generally well tolerated, it is less effective over time than ulipristal, should be used within 72 hours of exposure, and is less effective in patients with overweight and obesity (body mass index >25).
•Combined contraceptive pills (Yuzpe method) – This regimen (100 mcg of ethinyl estradiol and 0.5 mg of levonorgestrel historically given as two oral contraceptive pills (table 5) or its equivalent and repeated in 12 hours) is 75 to 80 percent effective if administered within 72 hours of intercourse but is rarely used given its lower efficacy and the high incidence of nausea and vomiting.
•Mifepristone – Mifepristone (600 mg single dose) is available for EC in some countries (not available in the United States).
●IUDs – The copper 380 mm2 and levonorgestrel 52 mg IUDs are the most effective forms of EC (pregnancy rates of less than 1 percent), may be inserted up to five days from exposure, and can remain in place to provide ongoing contraception. While IUD placement adds a procedure and may not be routinely performed by available personnel, a gynecology consult may be warranted to facilitate IUD insertion for patients at particularly high risk of conception (based on estimated timing of ovulation) or those who strongly desire to avoid pregnancy. Such insertion can often be done the next day in an outpatient setting. Additional information on IUD use for EC and types can be found in related content. (See "Emergency contraception", section on 'Intrauterine devices' and "Intrauterine contraception: Background and device types".)
Many patients will experience nausea and vomiting from the combination of antibiotics and contraceptives; HIV prophylaxis can also cause nausea and vomiting. Treatment with antiemetics is appropriate, and medications such as meclizine, ondansetron, or prochlorperazine are all reasonable choices. (See "Approach to the adult with nausea and vomiting", section on 'Drug therapy'.)
Psychosocial issues — Sexual assault victims require extensive emotional support and should be offered acute crisis counseling and mental health services. Victims should be referred for ongoing counseling ideally through sexual assault crisis programs. In the United States, the Rape, Abuse & Incest National Network (RAINN) operates a National Sexual Assault Hotline (800-656-HOPE) that automatically routes the caller to the nearest sexual assault service provider. (See "Date rape: Identification and management", section on 'Psychosocial support'.)
The medical evaluation and evidence collection process itself can be traumatizing and may compound the victim's sense of shame and loss of control. (See 'History and documentation' above.)
After assault, victims may experience anger, fear, anxiety, shame, guilt, insomnia, anorexia, intrusive thoughts, and physical pain (eg, musculoskeletal, genital, pelvic, and/or abdominal pain). Survivors of date rape should hear consistently from their health care providers that they are never to blame for a sexual assault.
Victims of sexual assault may also be victims of human trafficking (table 6 and table 7). (See "Human trafficking: Identification and evaluation in the health care setting".)
Safety planning — Acute crisis counseling should involve safety planning, which includes screening for suicidal ideation and self-harm behavior and asking if the victim is still in a relationship with the perpetrator. (See "Date rape: Identification and management", section on 'Safety' and "Intimate partner violence: Intervention and patient management", section on 'Assessing for safety'.)
Long-term implications — Sexual assault victims are at increased risk for a number of psychological, physical, and behavioral adverse effects, including the following [46-54]:
●Posttraumatic stress disorder (PTSD) – The risk may be greater when assaults occur repeatedly during the event, are perpetrated by more than one assailant, or are associated with physical injury; or the victim has a history of depression, acute stress disorder, or more than two prior traumas. Females with PTSD can suffer anxiety related to pelvic examination, labor, and giving birth; and they may avoid cervical cancer screening. (See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis".)
●Anxiety, phobias, depression, and suicide attempts. (See "Unipolar depression in adults: Clinical features" and "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis".)
●Revictimization. (See "Date rape: Identification and management", section on 'Preventing revictimization'.)
●Misuse of prescription sedatives, stimulants, steroids, and analgesics.
●Irregular menses, pelvic pain, dyspareunia, and urinary infections.
●Difficulty resuming hobbies, lifestyles, and sexual relationships.
●Decreased sexual satisfaction.
●Persistent sleep disturbances (eg, insomnia, nightmares).
●Anorexia.
Legal issues — Legal definitions, procedures, and reporting requirements vary by country and, in the United States, by state. Some jurisdictions do not define sexual assault to include male victims, and prosecution must occur under sodomy or other statutes.
The United States Violence Against Women Act (VAWA) creates and supports comprehensive, cost-effective responses to sexual assault, intimate partner violence, dating violence, and stalking. VAWA also allows for sexual assault examination without requiring law enforcement involvement. Many jurisdictions have policies that allow the patient to have evidence collected and stored for a given amount of time, leaving the patient the option to report to the police at a later date. The VAWA program also ensures patients are not required to pay for the services provided. VAWA’s reauthorization in 2022 continues to strengthen and modernize the law with improved services for all victims.
●Know mandatory reporting requirements – In most of the United States, only rapes involving children or elders require reporting by providers, while others require mandatory reporting for any sexual assault. Some jurisdictions may also require reporting for other special populations, such as residents of care facilities or patients under the care of a Department of Mental Health. Even when reporting is mandatory, victims can remain anonymous for examination and reporting purposes (eg, Jane Doe). (See "Date rape: Identification and management", section on 'Reporting requirements and confidentiality' and "Intimate partner violence: Intervention and patient management", section on 'Mandatory reporting'.)
●Factors impacting conviction – Successful prosecution appears to be associated with evaluation within 24 hours of assault, performance of a physical examination, documentation of anogenital trauma and other injury, the use of a weapon, and assault in the context of an intimate relationship [55-57]. Conviction rates range from 8 to 20 percent in the United States [39].
●Evidence-related issues – Evidence should be collected at the time of the initial evaluation and stored securely even if the patient is not planning to report the assault. Victims must sign consent forms prior to evidence collection. In addition, victims should be notified when the evidence is to be destroyed as mandated by United States law. In the United States, state-specific information on statistics and legislation regarding the backlog of untested kits can be found at http://www.endthebacklog.org/backlog/where-backlog-exists-and-whats-happening-end-it.
●Victim assistance services – In the United States, many states have witness assistance programs to provide advice on reporting, navigating the legal system, and victim financial compensation. The National Sexual Assault Hotline provides free and confidential services by phone and online chat (800-656-HOPE; rainn.org).
Follow-up care — A follow-up medical visit should occur within one to two weeks after the acute evaluation. This provides an opportunity to review psychosocial supports for the victim and to offer counseling. If STI treatment was not initially provided, a one-week medical visit is necessary to ensure follow-up of appropriate tests. At the follow-up visit, additional photographs of injuries can be taken to assess healing and document the injury timeframe.
●Improving compliance with follow-up – Compliance with follow-up medical care is often low among assault victims. Describing the short duration of the follow-up examination and the reasons for the visit at the initial evaluation and enlisting support from victim advocates are important ways to improve compliance. Permitting patients to return to the emergency department for follow-up care if no other medical facility is available or making home visits through nursing or community medicine programs are other potential options.
●Testing at follow-up visit — Pregnancy testing should be performed at follow-up, even if the patient received EC. Repeat testing for gonorrhea, chlamydia, trichomonas, and bacterial vaginosis should be done ideally one week after the assault in patients who declined prophylactic treatment. Testing is also indicated for those who develop interim symptoms and in those who request testing.
The CDC recommends rechecking rapid plasma reagin (RPR) at four to six weeks and three months and suggests offering HIV postexposure testing at the same intervals [37]. Others suggest performing serologic reexamination at 12 and 24 weeks only [17]. Patients should be counseled to abstain from intercourse until prophylactic treatment is completed and consider condom use until serologic testing is completed. Hepatitis B and HPV vaccination should be given at one month and six months to complete primary vaccination if indicated.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: HIV screening and diagnostic testing" and "Society guideline links: HIV prevention" and "Society guideline links: Sexual assault" and "Society guideline links: Sexually transmitted infections".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Care after sexual assault (The Basics)")
●Beyond the Basics topic (See "Patient education: Care after sexual assault (Beyond the Basics)".)
SUMMARY AND RECOMMENDATIONS
●Epidemiology – In the United States, 27 percent of females and 2 percent of males will be a victim of sexual assault during their lifetime. A minority of sexual assaults are reported to the police. (See 'Epidemiology' above.)
●History and physical examination – Evaluation of the sexual assault victim should be performed by a trained forensic provider, if possible. A detailed forensic history should be documented. Evaluation should include psychological assessment, evaluation of areas of trauma, and examination of the breasts and pelvic and anorectal areas. Colposcopy should be performed, when possible, to detect genital trauma. (See 'History and documentation' above and 'Physical examination' above.)
●Forensic evaluation – If deemed necessary, medical clearance (ie, medical issues and injuries have been addressed and stabilized) by a clinician should occur prior to the forensic exam. An evidence collection kit, with detailed instruction and containers for specimen collection, is necessary for a forensic evaluation. The victim should be evaluated as soon as possible after an assault, but evidence may be collected at later times depending upon factors such as patient history and hygiene. (See 'Forensic evaluation' above.)
●Laboratory testing – Screening for sexually transmitted infections (STIs) is not necessary if prophylactic treatment is to be given. Laboratory testing should include pregnancy testing in females of childbearing age. Baseline serology for syphilis and hepatitis B may be useful, and HIV counseling should be provided. Drug screening may be warranted if the victim was found unconscious or has amnesia for any time surrounding the event. (See 'Laboratory testing and diagnostic imaging' above.)
●Empiric STI treatment – In a sexual assault victim, we suggest treating empirically for gonorrhea, chlamydia, and trichomoniasis (Grade 2C). Empiric therapy includes ceftriaxone 500 mg by intramuscular injection, doxycycline 100 mg by mouth twice daily for seven days, and metronidazole 500 mg by mouth twice daily for seven days. In a patient for whom adherence may be a concern, azithromycin 1 g by mouth is an alternative to doxycycline, and metronidazole or tinidazole 2 g by mouth is an alternative to multidose metronidazole. (See 'Sexually transmitted infection post-exposure prophylaxis' above.)
•Vaccinations – Hepatitis B vaccine should be given to patients who have not been previously immunized (table 2 and algorithm 1). Human papillomavirus (HPV) vaccine should be given in age-eligible patients who have not been previously immunized. (See 'Hepatitis B infection' above and 'Human papillomavirus infection' above and "Human papillomavirus vaccination", section on 'Efficacy and immunogenicity' and "Management of nonoccupational exposures to HIV and hepatitis B and C in adults", section on 'Exposure to hepatitis B virus'.)
•HIV prophylactic treatment – Post-exposure prophylaxis against HIV infection should be given to a victim of sexual assault. Even though the risk of HIV transmission is low (table 3), we offer treatment if it can be initiated within 72 hours of exposure, and ideally within four hours. Antiviral regimens for post-exposure prophylaxis are discussed in detail separately. (See 'HIV infection' above and "Management of nonoccupational exposures to HIV and hepatitis B and C in adults", section on 'Antiviral therapy'.)
●Emergency contraception (EC) – We offer emergency postcoital contraception to all patients capable of pregnancy (table 4 and algorithm 2). Oral medication options include ulipristal acetate 30 mg given once, levonorgestrel (0.75 mg and repeated in 12 hours, or 1.5 mg as a single dose), and, in some regions, mifepristone. The copper 380 mm2 and the levonorgestrel 52 mg intrauterine devices (IUDs) are the most effective at preventing pregnancy and can be inserted up to five days from exposure. (See 'Preventing pregnancy' above and "Emergency contraception".)
●Acute crisis counseling – Sexual assault victims require extensive emotional support and should be offered mental health services. Many patients experience psychological and physical symptoms over many months following the assault. (See 'Psychosocial issues' above.)
●Follow-up care – Patient follow-up should occur by two weeks, with psychosocial counseling, STI testing for patients who did not take empiric therapy or who have symptoms, and pregnancy testing. Hepatitis B and HPV vaccines should be given at one and six months to complete the vaccine course. HIV and rapid plasma reagin (RPR) testing should be repeated at 12 and 24 weeks; some also recommend testing at six weeks. (See 'Follow-up care' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Carol K Bates, MD, who contributed to earlier versions of this topic review.
آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
