Sexual Assault Treatment & Management
- Author: William Ernoehazy, Jr, MD, FACEP; Chief Editor: Gil Z Shlamovitz, MD, FACEP more...
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 follows[12, 13]
Ceftriaxone 250 mg IM in a single dose, plus azithromycin 1 g PO in a single dose, plus metronidazole 2 g PO in a single dose or tinidazole 2 g PO in a single dose.
HPV vaccination is recommended for female survivors aged 9–26 years and male survivors aged 9–21 years. For men who have sex with men (MSM) who have not received the HPV vaccine or who have been incompletely vaccinated, vaccine can be administered through age 26 years. The vaccine should be administered to sexual assault survivors at the time of the initial examination, and follow-up dose administered at 1–2 months and 6 months after the first dose.[12, 13]
Recommendations for HIV PEP are individualized according to risk. According to the NY State Department of Health, the preferred PEP regimen for sexual assault is the same as that for other types of nonoccupational exposures and occupational exposures: Tenofovir 300 mg PO daily and Emtricitabine 200 mg PO daily plus Raltegravir 400 mg PO twice daily or Dolutegravir 50 mg PO daily.
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.
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.
Guidelines on postexposure prophylaxis of the sexual assault victim are available from the CDC and New York State Department of Health.[13, 14]
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