II. Definitions

  1. Sexual Violence
    1. Sexual acts either committed or attempted without consent (or inability to consent)
  2. Alcohol and Drug Facilitated Sexual Assault (ADFSA)
    1. Forced (or surreptitious) ingestion of Alcohol or Date Rape Drug used by perpetrators to facilitate Sexual Assault
  3. Sexual Assault (Crime)
    1. Non-consensensual sexual contact or behavior (e.g. rape or attempted rape, unwanted touching, sexual coercion)
  4. Rape (FBI)
    1. Body orifice (e.g. vagina, anus, mouth) non-consensual penetration by a sexual organ or object

III. Epidemiology

  1. Sexual Violence lifetime Incidence in U.S.: 40-50% of women and 30% of men
  2. Rape lifetime Incidence in U.S.: 18-25% of women and 4% of men
  3. Women represent 85% of Sexual Assault victims, and the perpetrators are male in >99% of cases
  4. Men represent 15% of Sexual Assault victims and the perpetrators are also male in 85% of cases
  5. Most perpetrators are known to the victim (as few as 14% of rapes are by strangers)
  6. Only 10% of Sexual Assaults involve a weapon (most commonly a knife)
  7. Rape survivors report the crime to law enforcement in only 16-38% of cases, and to primary providers in two thirds of cases
  8. Most perpetrators are motivated by sense of control more than sexual gratification (many experience Erectile Dysfunction)

IV. Risk Factors

  1. Physical or mental Disability
  2. Teenagers
  3. College Students
  4. Homelessness
  5. Child Abuse survivors
  6. Poverty
  7. Drug Abuse
  8. Alcohol Abuse
  9. Sex Workers
  10. Prisoners
  11. Geographic regions or unrest or military conflict
  12. Active duty military (>6% of active duty women)
  13. Lesbian, Gay, Bisexual, Transgender and Queer persons (LGBTQ)
    1. Transgender and bisexual persons have a 50% lifetime risk of Sexual Violence

V. Approach: Trauma Informed Care

  1. Safety
    1. Meet patient in private examination room
    2. Knock and door and ask for permission to enter patient room
    3. Thank patient for sharing their history and allowing evaluation
    4. Only ask patient to uncloth areas needed for exam (full exam performed by SANE nurse)
    5. Ask patient permission to perform examination
  2. Trustworthiness and Transparency
    1. As with all patients, tell patient what to expect for evaluation, duration
    2. Keep patient updated on findings, recommendations and allow time for questions
    3. All care team members should be aware of Trauma informed care, and introduce patient to them
  3. Peer Support
    1. Offer patient community resources
  4. Collaboration and mutuality
    1. Use supportive, non-technical language
    2. Understand patient worries, concerns
    3. Sit and face patient (and with non-confontrational body Posture)
  5. Empowerment, Voice and Choice
    1. Ask for verbal Informed Consent about each component of the evaluation
    2. Offer patient choices and follow their decisions with respect
    3. Allow patient to stop the evaluation if they need a break
  6. Cultural, Historic and Gender
    1. Ask about patient's values as they may relate to care and decisions
  7. References
    1. Sherman (2019) Fam Pract Manag 26(4): 19-23 [PubMed]

VI. Precautions

  1. Sexual Assault evaluation should be performed as soon as possible after event
  2. Patient should avoid activities that will alter evidence collection
    1. Avoid bathing
    2. Avoid changing clothes
    3. Avoid urinating or defecating if possible
    4. Avoid douching
  3. Medical providers should avoid destroying or contaminating evidence during their evaluation
    1. Wear non-powdered gloves
    2. Avoid obtaining urine specimen before SANE evaluation (esp. avoid cleaning wipes)
    3. Avoid oral or rectal medications
  4. Sexual Assault evaluation should be performed by trained provider
    1. Sexual Assault Nurse Examiners (SANE) are often called upon for this role (see below)
  5. Serious injuries and life threatening conditions take priority
    1. Evaluate and manage physical and mental health emergencies first

VII. History

  1. Performed by SANE or medical provider
  2. Use the patient's exact words
  3. Use the phrase "alleged Sexual Assault"
    1. Avoid the word "Rape" (legal term, not a medical term)
  4. Document specific details
    1. Age and other identifying details about the assailant (or multiple assailants)
    2. Date, time and location of assault
    3. Specific circumstances about the assault
      1. Include types of contact (kissing, sucking, biting, ejaculation or lack of ejaculation)
      2. Regions of penetration
      3. Use of Condom or lubricant
      4. Exposure to body fluids
    4. Restaints used by the assailant (e.g. weapons, drugs, physical force, Strangulation)
    5. Injuries
      1. Choking or Strangulation (up to 15-25% of Sexual Assaults)
        1. See Strangulation
        2. Important to identify due to risk of Carotid Artery injury
      2. Active pain or bleeding
      3. Bite marks or Bruising
  5. Document any cleaning (bathing, showering, wiping, douching) or clothes changing done by patient since the assault
  6. Last consensual sex, with whom and if recent, areas of penetration
  7. Obtain full gynecologic history
  8. Mental health
    1. Suicidality
    2. Homicidality

VIII. Exam

  1. Defer medical forensic exam to Sexual Assault Examiner (e.g. SANE Nurse) if available
  2. Evaluate for acute medical conditions or Traumatic Injury
    1. Avoid interfering with forensic exam and preserve any evidence including all clothing
    2. Document with photographs and body maps
  3. Body exam
    1. Head to toe evaluation
    2. Photographs of debris and injuries
    3. Alternative light source (e.g. wood's lamp) may reveal semen, vaginal secretions or Saliva (risk of False Positives)
    4. Collection of debris or biological evidence with 2 swab technique
      1. Evidence collection protocols are dictated by local jurisdiction
      2. Two lightly moistened cotton swabs lightly rolled over region, allowed to air dry, then packaged and labeled
  4. Anogenital exam
    1. SANE nurses examine, photograph, collect debris and swab for biological specimens in a systematic approach
      1. Alternative light source (e.g. wood's lamp) may be used to identify potential evidence sources
      2. Stains (e.g. toluidine blue) may be used and removed (with acetic acid, baby wipe or cotton swab with water-based libricant)
      3. Describe injuries in relation to a clockface (12:00 anterior, 3:00 left buttock, 6:00 posterior, 9:00 right buttock)
      4. Describe TEARS injuries (tears/Lacerations, Ecchymosis, abrasions, redness, swelling)
    2. Process
      1. External genitalia and vulva are examined, photographed and swabbed
        1. Focus on external genitalia and and vulva for most commonly injured structures
          1. Labia minora (inner labia or lips)
          2. Posterior fourchette (perineum on the edge of the posterior vaginal canal or vestibule)
          3. Fossa navicularis (superficial floor of the vaginal canal or vestibule)
        2. Retract the labia gently downward to reveal injury, debris or biological evidence
      2. Vaginal vault and Cervix are swabbed via speculum
        1. Colposcopy may be used
      3. Anus and Rectum are examined, photographed and swabbed
        1. Anal Spincter is examined
        2. Anal injury may be better visualized with touidine blue or with Anoscope

X. Labs

  1. Forensic Evidence with Rape Kit (typically performed by SANE)
    1. See exam above for process
    2. Evidence requires chain of custody (kept within clinician's line of sight or securely stored)
    3. Other evidence such as clothing, bedding should be dry and sealed in paper bags with patient's identifying name or ID
      1. Wet clothing will need to be air dried before storage (notify law enforcement if drying is needed before storage)
  2. Maximum time interval from assault for forensic lab collection (may vary by region, and may be extended in pediatric cases)
    1. Vaginal penetration: 120 hours or 5 days
    2. Anal penetration: 72 hours or 3 days
    3. Oral penetration: 24 hours or 1 day
    4. Bite marks or Saliva on skin surface: 96 hours or 4 days
  3. Urine Pregnancy Test (or blood qualitative Pregnancy Test)
  4. Vaginal and Endocervical Samples (consider repeating at 2 weeks)
    1. Gonorrhea PCR
    2. Chlamydia PCR
    3. Trichomonas vaginalis PCR
    4. Wet Prep (if symptomatic Vaginal Discharge)
      1. Bacterial Vaginosis
      2. Trichomonas
      3. Sperm are motile for up to 6 hours
    5. Consider Herpes Simplex Virus Testing to obtain baseline
  5. Serology
    1. Hepatitis B Surface Antigen
      1. On presentation and at 6 months
      2. Also consider Hepatitis B core IgM
    2. Hepatitis C
      1. Consider testing, depending on local protocols
    3. RPR for Syphilis Testing
      1. On presentation and at 4-6 weeks and 3 months (if assailant status unknown)
    4. HIV Test
      1. On presentation and consider at 6 weeks, 3 months and 6 months (if assailant status unknown)
  6. Alcohol and Drug Facilitated Sexual Assault (ADFSA, 33 to 66% of Sexual Assaults, with Alcohol most common)
    1. Urine Drug Screen and blood toxicology indications (typically within 72 to 96 hours of assault)
      1. Date Rape Drug suspected (e.g. Amnesia, severe Vomiting, Intoxication especially if out of proportion to Alcohol ingested)
      2. Testing should be sent to forensic lab (not hospital lab)
    2. Common substances (Date Rape Drugs)
      1. Chloral Hydrate
      2. Gamma Hydroxybutyrate (GHB)
      3. Ketamine (Ketalar)
      4. Benzodiazepines
        1. Flunitrazepam (sold legally in Europe and Latin America) accounts for 5% of U.S. Date Rape Drugs

XI. Management

  1. Sexual Assault Nurse Examiners (SANE) perform these Sexual Assault forensic exams in most regions of the United States
    1. http://www.forensicnurses.org/
    2. Forensic exams may be performed up to 5 days after assault (up to 7 days in some systems)
  2. Emergency medical providers work in conjunction with SANE nurse, to address Traumatic injuries
    1. Medical screening exam is typically performed on patient's emergency department arrival
    2. Serious injuries (e.g. Strangulation, active bleeding) should be addressed on patient arrival
    3. Non-critical injuries are typically deferred evaluation until after the forensic exam has been completed
    4. Hide the EMR documentation of the medical encounter from the patient portal (if possible)
    5. Diagnoses documented in the record should avoid terms "alleged" or "rule out"
      1. Preferred terms include "reported","evaluation following" or simply "Sexual Assault"
  3. Sexual Assault Response Team (SART) is multidisciplinary
    1. Patient advocate Consultation may be offered to ED patients while they are undergoing evaluation
    2. Police report is typically made from the Emergency Department (unless already reported)
      1. Adult patients with decision making capacity may refuse to make a police report
    3. Additional social services
      1. Rape crisis center and Domestic Violence agencies
      2. County protective services (e.g. Child Abuse, vulnerable adult)
  4. Emergency Contraception
    1. Provide Antiemetics with oral agents
    2. Levonorgestrel 1.5 mg for 1 dose (Plan B)
      1. May be given up to 72 hours after unplanned intercourse (up to 120 hours off-label use)
    3. Ulipristil (Ella) 30 mg orally once
      1. May be given up to 120 hours after unprotected intercourse
      2. Preferred if Body Mass Index (BMI) >25 kg/m2
    4. Copper-T Intrauterine Device
      1. May be inserted within 5 days of unprotected intercourse
  5. STD Prevention (perform all measures)
    1. Ceftriaxone 500 mg IM/IV for 1 dose (1 gram IM/IV if weight > 150 kg, dose increased in 2020)
    2. Azithromycin 1 g orally for 1 dose (or Doxycycline 100 mg twice daily for 7 days)
    3. Metronidazole 2 g orally for 1 dose or Tindazole 2 g for one dose
    4. HPV Vaccine (if not already vaccinated)
      1. Recommended for all patients 9 to 26 years old (and consider for age up to 45 years old)
    5. CDC as of 2010 guidelines does not recommend Valacyclovir for HSV prophylaxis (insufficient evidence)
  6. Hepatitis B
    1. Patient previously HepB immunized but unknown Immunity status and unknown assailant status
      1. Repeat Hepatitis B Vaccine for one additional dose
    2. Unknown HepB status and unknown assailant status
      1. Hepatitis B Vaccine series
    3. Survivor or assailant HepBsAg positive
      1. Hepatitis B Immunoglobulin
      2. Hepatitis B Vaccine series
  7. Consider HIV Prophylaxis in high risk exposure
    1. See HIV Postexposure Prophylaxis
    2. Assess HIV risk in assailant
      1. Vaginal intercourse risk: 0.1 to 0.2% HIV Transmission risk
      2. Rectal intercourse risk: 0.5 to 3% HIV Transmission risk
      3. Oral risk: Low HIV Transmission risk
    3. Assess for degree of mucosal Trauma, bleeding and other injuries associated with higher transmission risk
    4. Consider contacting National Clinician's Post-exposure Prophylaxis hotline (PEPline) at 888-448-4911
    5. If prophylaxis started
      1. Obtain baseline Complete Blood Count (CBC), BUN and Creatinine, Liver Function Tests
      2. Follow-up required in 7 days (and PEP is continued for 28 days)
  8. Other measures
    1. Tetanus Vaccine (Td, Adacel) Indications
      1. Higher risk open wound and last tetatus Vaccine >5 years ago
      2. Skin Abrasions and last Tetanus Vaccine >10 years ago
    2. HPV Vaccine
      1. Consider if not previously HPV vaccinated

XII. Prevention: Screening for Sexual Violence

  1. Two Question Screening Tool
    1. Have you ever been hit, slapped, kicked or otherwise physically hurt by your partner?
    2. Have you ever been forced to have sexual activities?
  2. Intimate Partner Violence Screening Tools
    1. SAFE Screen for Intimate Partner Violence
    2. HITS Screen for Intimate Partner Violence
    3. Women Abuse Screening Tool (WAST, WAST-SF)

XIII. Complications: Shortterm Following Assault

  1. Physical Injury (see above)
  2. Pregnancy (5%, higher in adolescents)
  3. Sexually Transmitted Infection (and Pelvic Inflammatory Disease)
    1. Chlamydia trachomatis (most common)
    2. Gonorrhea (common)
    3. Trichomoniasis (common)
    4. HIV Infection
      1. Risk 0.1 to 0.2% for vaginal intercourse (0.5 to 3% for receptive anal intercourse)
      2. Increased risk with mucosal Trauma

XIV. Complications: Longterm Following Assault

XV. Resources

  1. Sexual Assault Forensic Examiner technical assistance
    1. http://www.safeta.org
  2. Sexual Assault Nurse Examiners (SANE)
    1. http://www.forensicnurses.org/

XVI. Resources

  1. CDC Sexual Violence Data
    1. https://www.cdc.gov/violenceprevention/sexualviolence/datasources.html
  2. Rape, Abuse, Incest National Network Database (RAINN)
    1. https://rainn.org/
  3. National Sexual Assault Hotline
    1. Phone: 1-800-656-4673

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