eMedicine Specialties > Emergency Medicine > Psychosocial

Sexual Assault

Author: William Ernoehazy Jr, MD, FACEP, Medical Director, Emergency Department, Ed Fraser Memorial Hospital, Florida
Coauthor(s): Heather Murphy-Lavoie, MD, FAAEM, Assistant Professor, Section of Emergency Medicine and Hyperbaric Medicine, Louisiana State University School of Medicine, New Orleans; Clinical Instructor, Department of Surgery, Tulane University School of Medicine
Contributor Information and Disclosures

Updated: Feb 29, 2008

Introduction

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.

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.

Frequency

United States

The National Crime Victimization Survey for 2006 reported more than 272,350 sexual assaults — "rape, attempted rape or sexual assaults" — in the United States. 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.

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. 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.

Race

Sexual assault victims come from all socioeconomic and racial groups.

Sex

Most sexual assaults involve women. 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.

Clinical

History

  • After performing a preliminary survey to establish the presence of any potentially serious injury or illness, obtain further history from the victim. 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.

Physical

  • 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.

More on Sexual Assault

Overview: Sexual Assault
Differential Diagnoses & Workup: Sexual Assault
Treatment & Medication: Sexual Assault
Follow-up: Sexual Assault
References
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References

  1. Centers for Disease Control and Prevention, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. Aug 4 2006;55(RR-11):1-94. [Medline].

  2. Braun GR. Sexual assault. In: Emergency Medicine: Concepts and Clinical Practice. 3rd ed. St. Louis: Mosby-Year Book; 1992:2003-12.

  3. Ciancone AC, Wilson C, Collette R, et al. Sexual Assault Nurse Examiner programs in the United States. Ann Emerg Med. Apr 2000;35(4):353-7. [Medline].

  4. da Silva DA, Goes AC, de Carvalho JJ, de Carvalho EF. DNA typing from vaginal smear slides in suspected rape cases. Sao Paulo Med J. Mar 4 2004;122(2):70-2. [Medline].

  5. Das S, Huengsberg M. An audit on the management of female victims of sexual assault attending a genitourinary medicine clinic. Int J STD AIDS. Jul 2004;15(7):484-5. [Medline].

  6. Elliott DM, Mok DS, Briere J. Adult sexual assault: prevalence, symptomatology, and sex differences in the general population. J Trauma Stress. Jun 2004;17(3):203-11. [Medline].

  7. Ernst AA, Green E, Ferguson MT, et al. The utility of anoscopy and colposcopy in the evaluation of male sexual assault victims. Ann Emerg Med. Nov 2000;36(5):432-7. [Medline].

  8. Higgins SD, Schwartz GR. The sexually assaulted patient. Sexual assault evidence collection protocol, Office of the Attorney General. In: Principles and Practice of Emergency Medicine. 3rd ed. Williams & Wilkins; 1992:2418-31.

  9. Humphrey JA, White JW. Womens' vulnerability to sexual assault from adolescence to young adulthood. J Adolesc Health. Dec 2000;27(6):419-24. [Medline].

  10. Jones JS, Dunnuck C, Rossman L, et al. Significance of toluidine blue positive findings after speculum examination for sexual assault. Am J Emerg Med. May 2004;22(3):201-3. [Medline].

  11. Kenworthy T, Adams CE, Bilby C, et al. Psychological interventions for those who have sexually offended or are at risk of offending. Cochrane Database Syst Rev. 2004;CD004858. [Medline].

  12. Kintz P, Villain M, Ludes B. Testing for the undetectable in drug-facilitated sexual assault using hair analyzed by tandem mass spectrometry as evidence. Ther Drug Monit. Apr 2004;26(2):211-4. [Medline].

  13. Linden JA, Oldeg P, Mehta SD, et al. HIV postexposure prophylaxis in sexual assault: current practice and patient adherence to treatment recommendations in a large urban teaching hospital. Acad Emerg Med. Jul 2005;12(7):640-6. [Medline].

  14. 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. [Full Text].

  15. Mancino P, Parlavecchio E, Melluso J, et al. Introducing colposcopy and vulvovaginoscopy as routine examinations for victims of sexual assault. Clin Exp Obstet Gynecol. 2003;30(1):40-2. [Medline].

  16. Rand M, Catalano S. Criminal Victimization, 2006. U.S. Department of Justice, Bureau of Justice Statistics; Dec 2007. [Full Text].

  17. Reznic MF, Nachman R, Hiss J. Penile lesions -- reinforcing the case against suspects of sexual assault. J Clin Forensic Med. Apr 2004;11(2):78-81. [Medline].

  18. Sachs CJ. How To Convict A Rapist: Sexual Assault Response Teams. ACEP Scientific Assembly Proceedings. 1999.

  19. Sievers V, Murphy S, Miller JJ. Sexual assault evidence collection more accurate when completed by sexual assault nurse examiners: Colorado's experience. J Emerg Nurs. Dec 2003;29(6):511-4. [Medline].

  20. Stermac L, Del Bove G, Addison M. Stranger and acquaintance sexual assault of adult males. J Interpers Violence. Aug 2004;19(8):901-15. [Medline].

  21. Testa M, Vanzile-Tamsen C, Livingston JA. The role of victim and perpetrator intoxication on sexual assault outcomes. J Stud Alcohol. May 2004;65(3):320-9. [Medline].

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Further Reading

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Keywords

sexual assault, domestic violence, rape, impulse control disorders, post-assault emotional stress, posttraumatic stress disorder, post-traumatic stress disorder, PTSD, pregnancy, sexually transmitted diseases, STDs, male victims of sexual assault, female victims of sexual assault, Sexual Assault Nurse Examiner, SANE, Trichomonas vaginalis, T vaginalis

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Contributor Information and Disclosures

Author

William Ernoehazy Jr, MD, FACEP, Medical Director, Emergency Department, Ed Fraser Memorial Hospital, Florida
William Ernoehazy Jr, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Heather Murphy-Lavoie, MD, FAAEM, Assistant Professor, Section of Emergency Medicine and Hyperbaric Medicine, Louisiana State University School of Medicine, New Orleans; Clinical Instructor, Department of Surgery, Tulane University School of Medicine
Heather Murphy-Lavoie, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Undersea and Hyperbaric Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Francis Counselman, MD, Program Director, Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School
Francis Counselman, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Robert C Harwood, MD, MPH, Program Director, Chair, Department of Emergency Medicine, Christ Hospital and Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago Medical School
Robert C Harwood, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Associate Professor, Program Director, Department of Medicine, Division of Emergency Medicine, University of California at Los Angeles School of Medicine
Pamela L Dyne, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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