eMedicine Specialties > Emergency Medicine > Psychosocial

Sexual Assault

William Ernoehazy Jr, MD, FACEP, Medical Director, Emergency Department, Ed Fraser Memorial Hospital, Florida
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

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.

Differential Diagnoses

Other Problems to Be Considered

The above list, protean in its extent, reflects the overwhelming number of co-injuries that can occur during sexual assault, as well as the potential sequelae of such assaults.

Workup

Laboratory Studies

• 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 is problematic in EDs because of state and federal laws that stipulate mandatory counseling and follow-up care. Policy and guidelines should be established in advance with local sexual assault aftercare groups and OB/GYN services in accordance with prevailing law.
  • 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.¹ 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.

Imaging Studies

• Imaging studies are only indicated for evaluation of comorbid trauma.

Other Tests

• 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.

Procedures

• 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.

Treatment

Prehospital Care

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.

Emergency Department Care

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.
• At present, CDC guidelines for postsexual assault prophylaxis are as follows¹ :
  • Ceftriaxone 125 mg IM in a single dose, metronidazole 2 g PO in a single dose, and azithromycin 1 g PO in a single dose; or doxycycline 100 mg PO twice a day for 7 days
• Offer pregnancy prophylaxis if the pregnancy test results are negative. The current regimen of choice is 2 Ovral tablets PO in the ED, then 2 more tablets 12 hours later.
• Update tetanus status when necessary.
• Evaluate the patient's hepatitis B immunization status.
  • Postexposure hepatitis B vaccination, without hepatitis B immunoglobulin, should adequately protect against the hepatitis B virus.
  • Hepatitis B vaccine should be administered to sexual assault victims at the time of the initial examination if they have not been previously vaccinated. Follow-up doses of vaccine should be administered 1-2 months and 4-6 months after the first dose.
• 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.
• Provide reassurance and emotional support.

Consultations

• 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 a single sexual encounter is somewhere between 1:500 for known seropositivity and 1:5,000,000 for a low-risk assailant.

Medication

Medical intervention in sexual assault is focused on prevention of unwanted pregnancy and STDs. The recommendations below follow the most recent CDC guidelines, dated August 2006.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Ceftriaxone (Rocephin)

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.

Dosing

Adult

125 mg IM once

Pediatric

25-50 mg/kg IM as single dose (maximum 125 mg)

Interactions

Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy; caution in breastfeeding women

Cefixime (Suprax)

Former DOC for broad-spectrum prophylaxis of gonorrhea and syphilis. 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. No longer readily available; hence, no longer CDC recommended. FDA has approved Lupin Ltd to renew production, but they have yet to do so.

Dosing

Adult

400 mg PO once

Pediatric

Administer as in adults

Interactions

Coadministration of aminoglycosides increase nephrotoxicity; probenecid may increase effects of cefixime

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose with renal impairment

Metronidazole (Flagyl)

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.

Dosing

Adult

2 g PO once

Pediatric

40 mg/kg PO once

Interactions

May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity of metronidazole; disulfiram reaction may occur with orally ingested ethanol

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy

Azithromycin (Zithromax)

Treats mild to moderate infections caused by susceptible strains of microorganisms. Indicated for prophylaxis of chlamydial infections of the genital tract.

Dosing

Adult

1 g PO once

Pediatric

5-12 mg/kg/d PO for 15 d

Interactions

May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine

Contraindications

Documented hypersensitivity; hepatic impairment; do not administer with pimozide

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients

Doxycycline (Bio-Tab, Doryx, Vibramycin, Vibra-Tabs)

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.

Dosing

Adult

100 mg PO bid for 7 d

Pediatric

<8 years: Not recommended
>8 years: Administer as in adults

Interactions

Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy

Contraindications

Documented hypersensitivity; severe hepatic dysfunction

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines

Oral contraceptives

These agents are used to prevent unwanted pregnancies after sexual assault.

Estradiol and norgestrel (Ovral)

Inhibits ovulation by suppressing FSH and LH. Alterations that take place in the genital tract, including cervical mucus and the endometrium, may contribute to the effects of contraceptives.

Dosing

Adult

2 tab PO in ED, then 2 tab PO 12 h after first dose

Pediatric

Administer as in adults

Interactions

Onset of acetaminophen effect may be delayed or decreased slightly; hepatic metabolism of TCAs, caffeine, corticosteroids, benzodiazepines, beta-blockers, and theophylline may be decreased with increased therapeutic effects

Contraindications

Documented hypersensitivity; thrombophlebitis; known or suspected breast carcinoma or estrogen-dependent neoplasia; thromboembolic disorders; myocardial infarction; coronary artery disease; carcinoma of the endometrium; other hepatic adenomas/carcinomas

Precautions

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Caution in hepatic impairment, migraine, seizure disorders, cerebrovascular disorders, breast cancer, or thromboembolic disease; progestins may elevate LDL levels and decrease HDL levels, making hyperlipidemia control more difficult; depression may occur, attributed to a deficiency in pyridoxine; caution in patients with conditions that may be aggravated by fluid retention

Follow-up

Further Inpatient Care

• Patients with coexisting injuries or psychiatric symptoms may require inpatient care, with admission to the appropriate service.

Further Outpatient Care

• 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.

Transfer

• 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.

Complications

• Unwanted pregnancy
• STDs
• Posttraumatic stress reactions and disorders
• Morbidity and mortality (arising from physical injuries incurred during the sexual assault)

Prognosis

• The prognosis for sexual assault victims is generally favorable if adequate aftercare is available to assist the victim in recovery.

Patient Education

• 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, visit eMedicine's Public Health Center. Also, see eMedicine's patient education article Sexual Assault.

Miscellaneous

Medicolegal Pitfalls

• Failure to recognize and treat life-threatening injuries in the haste to obtain evidence
• Failure to offer adequate prophylaxis against pregnancy and STDs
• Failure to provide adequate documentation of the findings of a sexual assault examination, either by inappropriate preservation of physical evidence or by inadequate charting

References

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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. 3^rd 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].

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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

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.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous editor, Charles V Pollack Jr, MD, to the development and writing of this article.

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