Sexual assault is a broad term that includes rape, unwanted genital touching, and even forced viewing of or involvement in pornography. Rape is a legal term and in the United States refers to penetration of a body orifice without consent (mouth, vagina, or anus) and with force or the threat of force or incapacity (young or old age, cognitive or physical disability, or drug or alcohol intoxication). The definition of rape includes spousal rape (Linden, 2011). Rape is often motivated by aggression and rage, with the assailant using sexual contact as a weapon for power and control.
For sexual assault, large population-based surveys indicate a lifetime prevalence of 13 to 39 percent among women and 3 percent among men (Tjaden, 2000). Certain populations are at increased risk and include the physically or mentally disabled; homeless persons; persons who are gay, lesbian, bisexual, or transgendered; alcohol and drug users; college students; and persons younger than 24 (Lawyer, 2010).
Well-known sequelae of rape include isolation, depression, anxiety, somatic symptoms, suicide attempts, and posttraumatic stress disorder (PTSD). The experience has a strong effect on the victim’s subsequent health and thus is a major public health issue. Importantly, in caring for sexual assault victims, clinicians should be familiar with the complex array of reactions (emotional and physical), common injuries, and elements of proper evaluation and treatment of these patients.
Initial evaluation of a sexual assault victim concentrates on identifying serious injuries. Although 70 percent of rape victims sustain no obvious physical injuries, 24 percent sustain minor injuries, and up to 5 percent sustain major nongenital injuries. Common nongenital injuries include bruises, cuts, scratches, and swelling (81 percent); internal injuries and unconsciousness (11 percent); and knife or gunshot wounds (2 percent) (Sommers, 2001). In the genital area, the posterior fourchette is the area most often injured. Although death is rare, the fear of death during an assault is one of the most intense reactions (Deming, 1983; Marchbanks, 1990).
Once life-threatening injuries are excluded, a patient is ideally moved to a quiet, private setting for further evaluation. A systematic, thorough, but compassionate approach to obtaining a history and collecting evidence is essential for appropriate treatment of the victim and for future prosecution of her assailant (American College of Obstetricians and Gynecologists, 2014).
Examination and Documentation
Although valid evidence may be collected up to 5 days after sexual assault, immediate examination increases the opportunity to obtain valuable physical evidence (Table 13-11). Consent is obtained prior to physical and genital examination and evidence collection. This step helps to reestablish a victim’s sense of control and is essential for entry of evidence in a court of law (Plaut, 2004). Providers emphasize that vital information may be lost if evidence is not collected early. Moreover, evidence collection does not commit a victim to pressing criminal charges (Linden, 1999). A patient is also counseled that she may terminate an examination if it is too emotionally or physically painful.
TABLE 13-11Important Elements of Physical Examination and Evidence Collection Following Sexual Assault ||Download (.pdf) TABLE 13-11 Important Elements of Physical Examination and Evidence Collection Following Sexual Assault
|Physical examination |
Complete examination of head, body, and extremities; record injuries on body diagram
Pelvic examination, with colposcopy if available, to exclude lower reproductive tract trauma
|Elements of evidence collection |
Clothing collected in labeled paper bags
Swabs and smears of involved orifices and skin surfaces
Blood sample for patient blood typing to compare with assailant’s type
Head hair combings; then head hairs cut or pulled from patient for comparison
Pubic hair combings; then pubic hair cut or pulled from patient for comparison
Fingernail scrapings from the patient, if the victim scratched the assailant’s skin or clothing
Most states have standardized kits for evidence collection and storage in which kits may be locked to ensure that legal evidence procedures are maintained. Documentation of all physical injuries is essential, and objective evidence of trauma (even minor) is associated with increased chances of successful prosecution. Clothing is collected as a patient undresses on a white sheet and placed in properly labeled bags (Ingemann-Hansen, 2013). Any debris, such as hair, fibers, mud, or leaves, is also collected.
Evidence gathering includes a sample of the patient’s saliva and swabs of all involved orifices. A thorough pelvic examination with evidence collection is essential, even if there are no complaints of genital pain. Up to one third of victims can have traumatic genital injuries without symptoms. Common patterns of genital injury include tears of the posterior fourchette and fossa, labial abrasions, and hymenal bruising. Significant genital injuries are more common in postmenopausal or prepubertal victims. Colposcopy is used if available because this technique increases detection of more subtle injuries of the cervix and vagina. Lenahan (1998) reported that the use of colposcopy increased genital trauma recognition from 6 percent to 53 percent. In addition, a Wood’s lamp may aid identification of semen on the skin, which then is collected with moistened cotton swabs. A blood sample is collected for typing, to differentiate the blood type of the victim from that of the assailant. After evidence is collected, it is signed, sealed, and locked in a secure place (Mollen, 2012; Rambow, 1992).
Medication prophylaxis to prevent pregnancy and common sexually transmitted diseases is provided to women following sexual assault. The risk of rape-related pregnancy approximates 5 percent per rape among reproductive-aged victims (Holmes, 1996). Most of these pregnancies, unfortunately, occur in adolescents, often the victims of incest, who never report the incident or receive medical attention. Because of variation in a woman’s menstrual cycle, pregnancy prophylaxis, also termed emergency contraception, is offered to all victims with reproductive organs. Prophylaxis can be administered for up to 72 hours after rape but is most effective in the first 24 hours (Table 13-12). Some studies indicate that prophylaxis may be effective for up to 5 days following rape.
TABLE 13-12Pregnancy and Sexually Transmitted Disease Prevention Following Sexual Assault ||Download (.pdf) TABLE 13-12 Pregnancy and Sexually Transmitted Disease Prevention Following Sexual Assault
Pregnancy test (urine or serum)
Serum testing for hepatitis B surface antigen (HBsAg), HIV, and syphilis
Evaluation for Neisseria gonorrhoeae and Chlamydia trachomatis from each penetrated site
Microscopic evaluation of vaginal discharge saline preparation
If HIV PEP is planned, then CBC, serum liver function tests, and serum creatinine level
|Optional treatment |
A negative pregnancy test to exclude a preexisting pregnancy is confirmed before administering emergency contraception. This is especially true for ulipristal (Ella), a progesterone antagonist, because of fetal loss risks if used in the first trimester. With estrogen/progestin combinations, side effects include nausea and vomiting, breast tenderness, and heavier menstrual period. In comparison, with levonorgestrel (Plan B), the risk of nausea and vomiting is less (Arowojolu, 2002). An antiemetic can be prescribed 30 minutes prior to hormone administration to decrease nausea (Table 42-7).
Patients are informed that their next menses may be delayed following this prophylaxis. Although current regimens are 74 to 89 percent effective, women are counseled to return if their next menses is more than 1 to 2 weeks late (Task Force on Postovulatory Methods of Fertility Regulation, 1998; Trussell, 1996; Yuzpe, 1982).
Sexually Transmitted Disease Prevention
The risk of acquiring sexually transmitted disease (STD) after rape has been estimated. The risk for trichomoniasis approximates 12 percent; bacterial vaginosis, 12 percent; gonorrhea, 4 percent to 12 percent; chlamydial infection, 2 to 14 percent; syphilis, 5 percent; and human immunodeficiency virus (HIV) infection, 0.1 percent (Jenny, 1990; Katz, 1997; Schwarcz, 1990). However, these risks are difficult to predict and vary by geographic location, type of assault, assailant, and presence of preexisting infections. General recommendations describe prophylaxis for hepatitis, gonorrhea, and chlamydia (see Table 13-12).
The fear of contracting HIV after sexual assault is common in survivors and is often the primary concern following rape (Baker, 1990). However, postexposure prophylaxis (PEP) against HIV remains controversial, given the low risk of transmission after a single sexual assault (Gostin, 1994). With regard to sexual exposures, the per-contact risk of HIV transmission associated with receptive penile-anal exposures is estimated to be 0.5 to 3.2 percent and with receptive penile-vaginal exposures, 0.05 to 0.15 percent (Wieczorek, 2010). Although rare, HIV transmission associated with receptive oral intercourse has been reported. Experts recommend offering PEP to candidates who are at a higher risk of being exposed to HIV and who are willing to complete the full course of medications and comply with surveillance testing (Table 13-13). The risks and side effects of these medications and need for close monitoring is discussed with patients. Nausea is a common side effect with PEP. Thus, a prescription for an antiemetic such as phenergan, to be used as needed, is commonly provided. PEP should begin within 72 hours, if indicated. For sexual assault patients presenting outside of this time frame, information is provided regarding follow-up HIV antibody testing and referral options.
TABLE 13-13HIV PEP after Sexual Assault ||Download (.pdf) TABLE 13-13 HIV PEP after Sexual Assault
|Assess for risk of HIV infection in the assailant and test if possible |
|Determine characteristics of the assault that may increase the risk of HIV transmission (i.e., mucous membrane or broken skin in contact with blood, semen, or rectal secretions) |
|Consider consulting an HIV specialist or the National Clinicians’ Postexposure Prophylaxis Hotline: 888–448–4911 |
|If patient is at risk for HIV from assault, discuss PEP risks and benefits |
|If the patient starts PEP, schedule follow-up within 7 days |
|If prescribing PEP, obtain CBC, serum liver function tests, and serum creatinine level |
|Check HIV serology at baseline, 6 weeks, and then at 3 and 6 months |
Because of the emotional intensity of the experience, a woman may not recall all the information provided, and thus written instructions are helpful. Survivors are referred to local rape crisis centers and encouraged to visit within 1 to 2 days. Sexual assault victims receive subsequent medical evaluation at 1 to 2 weeks, and 2 to 4 months following their rape. During these visits, examination for STDs and blood testing for HIV and syphilis is performed. Remaining hepatitis vaccinations are administered, if needed.
Psychological Response to Sexual Assault
Survivors of sexual assault may display an array of reactions that frequently include anxiety, agitation, crying, or a quiet, calm, and removed affect. In 1974, Burgess and Holmstrom first characterized the “rape trauma syndrome.” They described two response phases to the trauma of sexual assault: (1) the acute disorganization phase, lasting several weeks, and (2) the reorganization phase, lasting from several weeks to years. During the acute phase, shock and disbelief, fear, shame, self-blame, humiliation, anger, isolation, grief, somatic manifestations, and loss of control are common. During the reorganization phase, feelings of vulnerability, despair, guilt, and shame may continue. Symptoms can include nonspecific anxiety, somatic complaints, or depression. Longitudinal data indicate that sexual assault survivors are at increased lifetime risk for PTSD, major depression, and suicide contemplation or attempt (Linden, 2011). Health care providers ideally enlist the input of social workers or rape crisis counselors to help evaluate the patient’s immediate and future emotional and safety needs.