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Editor's Note: This article has been updated to reflect new guidance from the Centers for Disease Control and Prevention on the treatment of gonococcal infection.

Am Fam Physician. 2021;103(3):168-176

Patient information: See related handout on sexual assault of women, written by the authors of this article.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial affiliations.

Sexual violence is a major public health and human rights issue affecting more than 40% of women in the United States during their lifetimes. Although men and women experience sexual assault, women are at greatest risk. Populations uniquely impacted by sexual assault include adolescents; lesbian, gay, bisexual, transgender, and queer people; and active-duty military service members. Health consequences of sexual assault include sexually transmitted infections, risk of unintended pregnancy, high rates of mental health conditions (e.g., posttraumatic stress disorder), and development of chronic medical conditions (e.g., chronic pelvic pain). Family physicians care for sexual assault survivors at the time of the assault and years after, and care should follow a survivor-centered and trauma-informed framework. Multiple organizations recommend screening all women for a history of sexual violence; however, the U.S. Preventive Services Task Force recommends only universal intimate partner violence screening in women of reproductive age. A validated tool, such as the Two-Question Screening Tool, can be implemented. Initial care should include treatment of physical injuries, prophylaxis for sexually transmitted infections, immunizations, and the sensitive management of psychological issues. Clinicians must comply with state and local requirements for the use of evidence-gathering kits. Many hospitals have developed collection protocols and employ certified Sexual Assault Nurse Examiners or Sexual Assault Forensic Examiners. Prevention of sexual violence requires a comprehensive approach to address individual, relational, community, and societal factors.

Definitions and Epidemiology

Sexual violence is a broad term that encompasses all sexual acts, committed or attempted, without consent or that occur when the person is unable to consent.1 The World Health Organization recognizes sexual violence as a global public health and human rights issue with far-reaching health consequences.2 Sexual assault is a crime involving nonconsensual sexual contact or behavior, which includes rape or attempted rape, unwanted touching, and sexual coercion.1 In 2012, the Federal Bureau of Investigation developed a comprehensive definition of rape, including any penetration (i.e., with a sexual organ or object) of a body orifice (e.g., vagina, anus, mouth) without consent.3 State laws related to sex crimes differ, and state-specific information is available in the Rape, Abuse and Incest National Network database (https://apps.rainn.org/policy/).

WHAT'S NEW ON THIS TOPIC

Sexual Assault of Women

The National Intimate Partner and Sexual Violence Survey revealed that 43.6% of women experienced sexual violence in their lifetimes, with one in five women experiencing rape or attempted rape.

Approximately 6% of women in the active-duty military reported experiencing sexual assault in the past year.

Among survivors of rape, 16% to 38% report the crime to law enforcement, with similar percentages presenting for medical evaluation.

Widespread underreporting of sexual assault impacts estimates of incidence and prevalence. The National Intimate Partner and Sexual Violence Survey reported that 43.6% of women experienced sexual violence in their lifetimes, with one in five women experiencing rape or attempted rape.4 Fifty to 80% of sexual assaults are committed by a person known to the survivor.5,6 This article focuses on women; however, sexual violence is increasingly reported among men, with one in four experiencing sexual violence during their lifetimes.4

Populations at increased risk include people who are physically or mentally disabled, adolescents, college students, homeless people, survivors of child maltreatment, people living in poverty, users of drugs or alcohol, people who engage in sex work, and people living in prisons, institutions, or areas of military conflict.4,710 Among women in the active-duty military, 6.2% surveyed reported experiencing sexual assault in the past year.11 Approximately one-half of transgender people and bisexual women experience sexual violence in their lifetimes.12,13 Lesbian, gay, bisexual, transgender, and queer populations face higher rates of hate-motivated violence, which can involve sexual assault, and are less likely to access the medical system, legal system, and support services because of discrimination and a fear of being “outed.”4,12 Children and adolescents are at risk of sexual violence, and American Family Physician has reviewed complexities unique to this population separately.14,15

Rape is the most underreported crime.4 Among survivors of rape, 16% to 38% report the crime to law enforcement, with similar percentages presenting for medical evaluation. Approximately two-thirds of survivors will disclose the assault to their primary care physician.16,17 This article reviews key aspects of clinical care for women who are sexual assault survivors. A reference to the American Academy of Family Physicians' policy statement on sexual assault and other recommended resources for clinicians are listed in Table 1.

American Academy of Family Physicians
Policy statement on treatment of survivors of sexual assault
https://www.aafp.org/about/policies/all/sexual-assault.html
Policy statement on rights, protections, and support for survivors of sexual assault
https://www.aafp.org/about/policies/all/sexual-assault-rights.html
FPM Journal
Communication tips for caring for survivors of sexual assault
https://www.aafp.org/fpm/2019/0700/p19.html
National Sexual Violence Resource Center
Directory of sexual assault centers in the United States
https://www.nsvrc.org/organizations or 877-739-3895
Pennsylvania Coalition Against Rape
Put down the chart, pick up the questions: a guide to working with survivors of sexual violence
https://www.nsvrc.org/sites/default/files/2017-09/put_down_the_chart_pick_up_the_questions.pdf
Rape, Abuse and Incest National Sexual Assault Hotline (1-800-656-HOPE)
Refers survivors to local rape crisis centers
https://www.rainn.org/about-national-sexual-assault-telephone-hotline
Sexual Assault Forensic Examiner technical assistance
Technical assistance and essential information about sexual assault medical forensic examinations
https://www.safeta.org/
U.S. Department of Justice, Office on Violence Against Women
National protocol for sexual assault medical forensic examinations
https://www.ncjrs.gov/pdffiles1/ovw/241903.pdf

Health Sequelae of Sexual Assault

Sexual assault has short- and long-term consequences on women's physical, mental, sexual, and reproductive health. Short-term health implications include physical injuries, sexually transmitted infections (STIs), and pregnancy. Acute physical injuries range in severity from abrasions and bruises to concussions, fractures, and bullet wounds. The likelihood of pregnancy after sexual assault is approximately 5%, with higher rates among adolescents.18 When rape does result in pregnancy, patients are more likely to choose to terminate the pregnancy than to continue it.17 The risk of acquiring an STI after sexual assault is influenced by local prevalence rates and the type of assault.5 The most common STIs reported in sexual assault survivors are Chlamydia trachomatis, gonorrhea, and trichomoniasis. Chlamydia and gonorrhea may lead to pelvic inflammatory disease and infertility if untreated. The risk of HIV transmission from vaginal intercourse is 0.1% to 0.2% and for receptive anal intercourse is 0.5% to 3% and may be increased with mucosal trauma.19

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