Sexual Assault Treatment & Management

  • Author: William Ernoehazy Jr, MD, FACEP; Chief Editor: Pamela L Dyne, MD   more...
 
Updated: Dec 3, 2009
 

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.

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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[4] :
    • 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.
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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.
  • Guidelines on postexposure prophylaxis of the sexual assault victim are available from the CDC and New York State Department of Health.[4, 5]
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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, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

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: Alpha Omega Alpha, American College of Emergency Physicians, Association of Academic Chairs of Emergency Medicine (AACEM), Norfolk Academy of Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Robert Harwood, MD, MPH, FACEP, FAAEM  Program Director, Department of Emergency Medicine, Advocate Christ Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago College of Medicine

Robert Harwood, MD, MPH, FACEP, FAAEM 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.

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  Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

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  2. Jones JS, Rossman L, Diegel R, Van Order P, Wynn BN. Sexual assault in postmenopausal women: epidemiology and patterns of genital injury. Am J Emerg Med. Oct 2009;27(8):922-9. [Medline].

  3. [Guideline] Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. Sep 22 2006;55:1-17; quiz CE1-4. [Medline].

  4. [Guideline] 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].

  5. [Guideline] New York State Department of Health. HIV prophylaxis following non-occupational exposure including sexual assault. Jan 2008;[Full Text].

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

  7. 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].

  8. 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].

  9. 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].

  10. 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].

  11. 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].

  12. 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.

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

  14. 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].

  15. 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].

  16. 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].

  17. 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].

  18. 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].

  19. 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].

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

  21. 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].

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

  23. 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].

  24. 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].

  25. 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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