Sexual Assault

Updated: Nov 10, 2015
  • Author: William Ernoehazy, Jr, MD, FACEP; Chief Editor: Gil Z Shlamovitz, MD, FACEP  more...
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Overview

Practice Essentials

Sexual assaults are distinguished from other assaults by forcible, inappropriate sexual behavior. 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 and/or lack of consent, 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

Posttraumatic stress disorder (PTSD) can also result from sexual assault, as can unwanted pregnancy and sexually transmitted disease infection.

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 sexually transmitted disease (STD), 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.

Pregnancy prophylaxis, such as Ovral tablets, 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.

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Background

Patients who come to the ED 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.

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Pathophysiology

Sexual assaults are distinguished from other assaults by forcible, inappropriate sexual behavior. Sexual assault is an act of violence, not of sexual gratification. Sex is the weapon; it is a means, not the end.

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]

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Frequency

The National Crime Victimization Survey for 2014 reported 284,350 rape/sexual assaults in the United States. [2] It is certain that many more assaults occur than are reported due to postassault stress and misplaced shame levied against the victim. Current best estimates indicate that 1 in 6 women and 1 in 33 men will be the victim of a sexual assault at least once in their lifetime.

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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.

  • Posttraumatic stress disorder (PTSD) can cause long-term psychological impairment. [3] 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.

 

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Epidemiology

Race

Sexual assault victims come from all socioeconomic and racial groups. 

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". [4]

Sex

Most sexual assaults involve women. [5]  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 2013 national Youth Risk Behavior Survey administered by the Centers for Disease Control and Prevention assessed the risk of teen dating violence (TDV), both physical and sexual. The results show that, among students who dated, 20.9% of female students (95% CI, 19.0%-23.0%) and 10.4% of male students (95% CI, 9.0%-11.7%) experienced some form of TDV during the 12 months before the survey. Female students had a higher prevalence than male students of physical TDV only, sexual TDV only, both physical and sexual TDV, and any TDV. [6]

A recent 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. [7]  Another study showed an average age of 27 years among women who presented to an ED. [4]

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