Sexual violence includes intimate partner violence, human trafficking, forced prostitution, bondage, exploitation, neglect, infanticide, and sexual assault. It occurs worldwide and affects up to one third of women over a lifetime.1 Sexual assault includes vaginal, oral, and anal penetration and is more broadly conceived than the legal definition of rape as nonconsensual penetration by a penis. Sexual assault is underreported, and the wide range in estimated lifetime prevalence reflects the method of data collection, with lower rates (12 to 20 percent) reported in persons presenting for medical care and higher rates (20 to 30 percent) reported in community surveys.2 Fifty to 80 percent of sexual assaults are committed by a person known to the survivor.1,3,4 Less than one fourth of survivors report sexual assault to the police.4
|Clinical recommendation||Evidence rating||References||Comment|
|Emergency contraception should be offered to all sexual assault survivors who are of childbearing potential and have a negative pregnancy test.||C||8||Based on expert opinion|
|All sexual assault survivors should be treated for the prevention of sexually transmitted infections.||C||9||Based on expert opinion|
Sexual violence is an act of aggression by the powerful against the less powerful. Although both men and women can be sexually assaulted, women are at greatest risk. Some groups are particularly vulnerable, including adolescents; survivors of childhood sexual or physical abuse; persons who are disabled; persons with substance abuse problems; sex workers; persons who are poor or homeless; and persons living in prisons, institutions, or areas of military conflict.1,4,5 This article reviews treatment of women who have been sexually assaulted and the long-term sequelae of sexual assault. Reference to the American Academy of Family Physicians policy statement on sexual assault can be found in Table 1, along with a list of other recommended resources that provide information beyond the scope of this article.
|American Academy of Family Physicians. Rape victim treatment.|
|Web site: https://www.aafp.org/about/policies/all/rape-victim.html|
|Policy statement on treatment of persons who have been raped|
|Ernoehazy W Jr, Murphy-Lavoie H. Sexual assault. eMedicine. February 29, 2008.|
|Web site: http://emedicine.medscape.com/article/806120-overview|
|Article on care of persons in an emergency department who have been sexually assaulted|
|U.S. Department of Justice, Office on Violence Against Women. A national protocol for sexual assault medical forensic examinations. September 2004.|
|Web site: http://www.ncjrs.gov/pdffiles1/ovw/206554.pdf|
|Sexual Assault Forensic Examiner technical assistance.|
|Web site: http://www.safeta.org/|
|Resources for sexual assault forensic examiners|
Care of the Sexual Assault Survivor
Immediate treatment of a woman who has been sexually assaulted should address three areas: legal, medical, and psychosocial. Care is coordinated among law enforcement officers, medical personnel, and psychosocial support staff. It is critical that the survivor be assured that she is safe and not to blame for the assault.
Most women who have been sexually assaulted will present to the emergency department. If a woman presents to the family physician's office, the physician should determine if he or she can evaluate the patient appropriately and, if necessary, discuss referral with her. The decision to refer should be based on: (1) the availability of another site for assessment; (2) time available to complete the evaluation (30 to 60 minutes for the actual visit, with further time for coordination of legal, social, and psychological care)6; (3) experience with evaluation and treatment of sexual assault survivors; and (4) the ability to collect and preserve appropriate evidence (e.g., having the contents of a “rape kit” available [Table 26]). The benefits of seeing the woman in the family physician's office include a less intimidating environment and an established relationship with the physician. If the survivor decides to report the assault, the local law enforcement agency should be contacted.
|Instructions, check-off form, and history and physical examination documentation forms||To ensure that all appropriate evidence is collected|
|Large paper sheet||For patient to stand on while undressing, to collect any evidence that may fall off in the process of undressing|
|Paper bags||To collect and label evidence (DNA may degrade in a moist environment, which is why plastic is not used)|
|Cotton-tipped swabs||To collect samples from oropharynx, vagina, and rectum|
|Comb||To collect evidence from pubic hair|
|Filter paper||To remove evidence from the comb|
|Small cardboard boxes||To transport red- and purple-topped tubes used to collect blood samples and other evidence|
|Patient discharge instructions||To include information with available local community resources, follow-up appointment information, and appropriate telephone numbers|
EVALUATION AND TREATMENT OF INJURIES
Using a gentle, nonjudgmental approach, the health care professional taking the history should document it in the patient's own words (Table 36). As with any trauma, the history may seem to be disjointed and asynchronous. A woman may think that she did something to cause the assault and that others will blame her. Obtaining the patient's consent at each step of the examination helps her to regain a sense of control over the situation and is often a legal requirement. If available, a videotape explaining the evaluation procedures or the presence of a victim advocate is helpful.
|Use the patient's exact words|
|Use the phrases “alleged sexual assault” or “sexual assault by history”; avoid using “rape” because it is a legal, not medical, term|
|Document the ages of and identifying information about the patient and the assailant; the date, time, and location of the assault; the specific circumstances of the assault, including details of sexual contact and any exposure to bodily fluids; and what the patient has done since the assault (e.g., bathing, douching, changing clothes)|
|Note use of restraints (e.g., weapons, drugs, alcohol)|
|Record the patient's gynecologic history (including most recent consensual sexual encounter)|
The physical examination begins with an assessment for injuries. Injuries are noted in approximately one half of all reported assaults, and nongenital injuries are more common than genital ones.4 Many facilities use a body diagram as part of the medical record to document the location of, size of, and specific information about physical injuries, such as abrasions, lacerations, bite marks, scratches, and ecchymoses. Alternatively, photography can be used with patient consent. Most physical injuries are minor, but any major trauma requires immediate attention and takes priority over further forensic evaluation.4 In the absence of major trauma, collection of evidence is done concurrently with the physical examination.
COLLECTION OF APPROPRIATE EVIDENCE
The chain of evidence, or chain of custody, refers to the documentation of what evidence (e.g., sperm samples, torn clothing) is collected, when, and by whom, as well as how it is subsequently transported. Documentation of the designated person or persons who have physical custody of the evidence is required. The chain of evidence is critical for potential future legal proceedings. Most emergency departments have a rape kit and protocol, but an office-based physician may need to assemble one. Evidence to be collected includes: the patient's clothing; fingernail scrapings; head and pubic hair combings; plucked hair from the patient; swabs of the oropharynx, vagina, and rectum; and blood samples.6 Patient discharge information includes local community resources and follow-up plans. Because of the potential legal implications of evidence collection in sexual assault cases, physicians are cautioned against making their own rape kit, unless absolutely necessary.
Drug-facilitated sexual assault should be considered when the survivor reports amnesia (partial or total) or the sense that “something sexual happened.”7 The presence of drugs or alcohol may be used as an excuse by the perpetrator and to blame the woman for the sexual assault.2,7 The substance most commonly associated with sexual assault is alcohol, often combined with over-the-counter, prescription, or illegal drugs. Drugs used include chloral hydrate, gamma hydroxybutyrate, ketamine (Ketalar), and benzodiazepines (e.g., flunitrazepam [Rohypnol]). They are detectable in the urine up to 72 hours after use. Flunitrazepam and gamma hydroxybutyrate are illegal drugs and not obtained by a prescription.
PREVENTION OF PREGNANCY AND SEXUALLY TRANSMITTED INFECTIONS
Although the risk of pregnancy after a sexual assault is relatively low (approximately 5 percent), emergency contraception should be offered to all women of childbearing potential with a negative pregnancy test (Table 4).8,9 The only absolute contraindication to emergency contraception is a confirmed pregnancy.8 Emergency contraception is most effective within 12 hours of unprotected sexual intercourse, and continues to be effective for up to five days.4
|Sexually transmitted infections|
|Hepatitis B vaccination (if not immune)|
|Gonorrhea, chlamydia, and trichomoniasis|
|Ceftriaxone (Rocephin), 125 mg intramuscularly|
|Metronidazole (Flagyl), 2 g orally|
|Azithromycin (Zithromax), 1 g orally, or doxycycline, 100 mg orally twice daily for seven days|
|Levonorgestrel (Plan B), two pills taken at once (other hormonal emergency contraceptive formulations are also acceptable)|
All survivors of sexual assault should be treated to prevent sexually transmitted infections (STIs).9 Initial laboratory evaluation after a sexual assault is outlined in Table 5.6,9 Repeat testing for syphilis and human immunodeficiency virus (HIV) should be performed at six weeks and again at three and six months after the assault.9 Prophylaxis for STIs should be offered because follow-up may be unreliable (Table 4).8,9
|Serum||Venereal Disease Research Laboratory or rapid plasma reagin|
|Human immunodeficiency virus|
|Hepatitis B (surface antigen and immunoglobulin M antibodies to hepatitis B core antigen); hepatitis C not routinely recommended|
|Vaginal, anal, or oral swab (at any site of penetration)||Culture or antigen testing for Neisseria gonorrhoeae and Chlamydia trachomatis|
|Wet mount prepraration for detection of sperm (motile for approximately six hours)|
|Vaginal only: clue cells associated with bacterial vaginosis and Trichomonas vaginalis|
The risk of acquiring HIV infection after a sexual assault depends on the local prevalence of the virus and the type of assault.4 According to the Centers for Disease Control and Prevention, the per-episode risk of acquiring HIV infection in consensual sex is 0.5 to 3 percent from receptive anal intercourse, 0.1 to 0.2 percent from vaginal intercourse, and less from oral sex,9 but risk of transmission may be increased with mucosal trauma and bleeding. Postexposure prophylaxis should begin within 72 hours, if indicated (Table 6).9
Survivors of sexual assault should be instructed to seek medical evaluation if symptoms of STIs develop, to abstain from sexual contact until completion of prophylactic treatment, and to schedule a follow-up appointment one to two weeks after the assault. They should also be encouraged to contact a local sexual assault crisis center, if available.
|Assess for risk of HIV infection in the assailant|
|Determine characteristics of the assault that may increase the risk of HIV transmission (i.e., mucosal trauma and bleeding)|
|Consider consulting an HIV specialist (or consult the National Clinicians' Post-Exposure Prophylaxis Hotline [PEPline]: 888-448-4911)|
|Discuss low seroconversion rates in a risk-targeted approach and highlight the toxicity of routine antiretroviral prophylaxis|
|If the patient starts postexposure prophylaxis, schedule follow-up within seven days|
|When prescribing postexposure prophylaxis, obtain a complete blood count and chemistry panel at baseline|
|Check HIV serology at baseline, six weeks, and three and six months|
PROVIDING PSYCHOSOCIAL SUPPORT
Psychological sequelae vary among women who have been sexually assaulted. Survivors may immediately present with symptoms of disbelief, anxiety, fear, emotional lability, and guilt.6 The “second rape” refers to secondary victimization from legal, medical, and mental health systems.10 Physician training and the presence of victim advocates have improved responsiveness, but up to one half of women report unhelpful or harmful contacts and inconsistent medical care. Survivors report “cold, impersonal, and detached” treatment by health care professionals.10 Rape myths are pernicious, endemic, and often internalized. Common examples include the sentiments that it could not be rape because, “they were lovers,” “she was not hurt,” “she is too old,” or “she (or he) was drunk.” For every 100 rape cases reported, seven may result in a prison sentence.10 Sexual assault affects not only the survivor, but also her family, friends, and significant other.3
Long-Term Issues Associated with Sexual Assault
Trauma disclosure is a process, and sexual assault survivors may give this history to family physicians days to decades after the assault. Family physicians may learn about a sexual assualt just days after it occurred while providing care in the office or months after it occurred while treating patients with post-traumatic stress disorder (PTSD). A patient may have difficulty with pelvic examinations even years after the assault.11 Patients are more likely to reveal a sexual assault history when directly asked; however, disclosure is less likely as the rape deviates from the stereotypical scenario of stranger rape. Survivors, even years later, need to report their trauma in their own manner.
There is no definitive cutoff for collecting a rape kit after a sexual assault; however, it is difficult to collect evidence after 48 to 72 hours. Clothing can be collected for up to one month for DNA evidence if it has not been laundered or stored in a moist environment (which may destroy evidence).6 STI treatment and pregnancy prevention may still be necessary. Assuring the survivor that she is safe is paramount.
PHYSICAL AND PSYCHOLOGICAL SEQUELAE
Sexual assault may be associated with pelvic pain, other chronic pain syndromes, headaches, irritable bowel syndrome, fibromyalgia, and sexual dysfunction (Table 76). In one pelvic pain clinic, 46 percent of patients had a history of abuse.12 Two other studies found that women with a history of sexual assault experienced more abdominal pain from their irritable bowel syndrome13 and pain with speculum insertion during routine pelvic examination.14
|Chronic pain (pelvis, back)|
|Irritable bowel syndrome|
|Poor overall health status|
|Alcohol and drug abuse|
|Posttraumatic stress disorder|
Although the most common psychological sequela of sexual assault is PTSD, with reported rates of 30 to 65 percent,15 depression, anxiety, substance abuse, and eating disorders may also result. Predictors of PTSD severity include characteristics of the survivor and the assault (e.g., perceived life threat, use of violent force); negative reactions to disclosure; ethnicity (minorities experience more severe PTSD); and previous abuse, depression, or alcoholism.15,16
Young women (16 to 24 years of age) are four times more likely to be sexually assaulted than women of any other age,17 and dating violence or date rape estimates range up to 30 percent.18 Adolescents who have been sexually assaulted not only have long-term medical and psychological effects, but they are also at high risk of revictimization, criminal behavior,19 and future self-destructive behaviors, including high-risk sexual practices, intravenous drug use, prostitution, and delinquency.17
SEXUAL ASSAULT AND WAR
Women and children are at risk of sexual assault during conflict, when fleeing conflict, and in displacement. Rape persists as a strategy of war and as an opportunistic offense perpetrated by persons with power in locations lacking security.20
OTHER AT-RISK GROUPS
Older women are more likely to be assaulted by a stranger or a health care worker, are more commonly assaulted in their homes or health care facilities, and incur greater genital trauma.23–25 Women with physical disabilities are also at increased risk.26,27 In both of these groups, data are poor because there is often coexisting cognitive disability.
Women living in detention facilities are at high risk of sexual assault, but accurate data are hard to obtain.28
Primary prevention of violence is societal. Effective programs confront public attitudes about love and sexuality and teach conflict resolution skills. Teaching women life skills may decrease their vulnerability to sexual violence. Safety and support programs (e.g., telephone hotlines), transportation policies and procedures, campus and community safety programs, and crime prevention programs have been shown to decrease the incidence of sexual assaults.30
Initial recognition that a sexual assault has occurred and effective care of survivors represent secondary prevention for the survivor, but primary prevention of revictimization. The availability of victim advocates and training programs for physicians and other health care professionals, such as Sexual Assault Nurse Examiner programs, improves care and provides accurate collection and documentation of forensic evidence, which improves prosecution rates.3,10