Sexual Assault of Male Victim

Aka: Sexual Assault of Male Victim, Male Rape Victim

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II. Epidemiology

  1. Rape lifetime Incidence: 1.4% to 4% of U.S. men (typically before at 25 years old)
    1. However, this number may be an underestimate with some studies with lifetime Prevalence as high as 3-7%
      1. Coxell (1999) BMJ 318:846-50 [PubMed]
    2. Contrast with rape lifetime Incidence of 18% in women
    3. However, lifetime Incidence of other Sexual Violence is approximately 5% for both genders
  2. Perpetrators of male victim rape are also male in 80 to 85% of cases
    1. However females are more common perpetrators of other Sexual Violence (e.g. made to penetrate, sexual coercion)
    2. Perpetrators are known to the victim in most cases (52% acquaintance, 29% intimate partner)
    3. More than one perpetrator is twice as common in the rape of male victims than femal victims
  3. Male victims tend to be less willing to report rape than females
    1. However, males are more likely to report rape by strangers, especially if injury was sustained
  4. Male victims are heterosexual in 68% of rapes

III. Risk Factors: Sexual Assault with Male Victims

  1. Jail or Prison Inmate (2-5% of male Prison Inmates, more than half by staff perpetrators)
  2. Institutionalized
  3. Homeless
  4. Transgender
  5. Physically disabled
  6. Cognitive Impairment
  7. Mental health patient
  8. College students (5-8% of male college students)
  9. Military personnel (up to 1.8% of active duty males)
  10. Gang members

IV. Presentations

  1. Intoxication
    1. Volitional or forced Alcohol consumption
    2. Date Rape Drug (e.g. Benzodiazepines, Diphenhydramine, Rohypnol, Gamma Hydroxybutyrate)
      1. See Date Rape Drug
  2. Musculoskeletal or other non-sexual Trauma (e.g. Physical Restraint)
    1. Systemic injuries in 66% of patients
    2. Multiple assailants are twice as likely to be involved in male Sexual Assault
  3. Oral Trauma
    1. Oral penetration in 43% or patients
    2. Pharyngeal Gonorrhea is not uncommon after forced oral penetration
  4. Anal Trauma (esp. digital, fist or object penetration)
    1. Anal penetration in 67% of patients
    2. External effects
      1. Anal tears, fissures, bleeding, tenderness, or Hematoma
    3. Internal effects (may require general surgery evaluation under Anesthesia)
      1. Traumatic Proctitis
      2. Retained Foreign Body
      3. Anal sphincter disruption
      4. Rectal mucosal Laceration
      5. Rectosigmoid transmural perforation

V. Labs: Sexually Transmitted Infection

  1. Dirty Urine Samples or from male Urethra (consider repeating at 2 week)
    1. Gonorrhea PCR
    2. Chlamydia PCR
  2. Other samples
    1. Pharyngeal Gonorrhea Culture (do not use PCR swabs on throat due to cross reacting oral flora)
    2. Rectal Chlamydia and Gonorrhea Cultures
    3. Papp (2014) MMWR Recomm Rep 63(RR02):1-19 +PMID:24622331 [PubMed]
  3. Serology initially, at 4 months, and again at 6 months for HIV (some recommend all tests at 6, 12 and 24 weeks)
    1. Hepatitis B Surface Antigen (and consider Hepatitis B core IgM)
      1. Consider Hepatitis B Surface Antibody to confirm Immunity
    2. RPR for Syphilis Testing
    3. HIV Test
  4. Other testing if prophylaxis started
    1. HIV Post Exposure Prophylaxis
      1. Complete Blood Count
      2. Alanine Aminotransferase (ALT)
      3. Serum Creatinine

VI. Management

  1. Same Rape Management approach as with Female Rape Victim
  2. Initial emergency department management
    1. Ensure patient safety
    2. Medical screening exam and evaluate for serious injury or complication
      1. Avoid destruction or alteration of physical evidence prior to SANE evaluation
      2. Manage serious and life threatening injuries via ATLS protocol
      3. Perform standard wound and Fracture care management
    3. Assess prophylactic medication indications (SANE will also make recommendations)
      1. See regimen below
  3. Forensic exam by Sexual Assault Nurse Examiner (SANE)
    1. Transfer may be needed to facility able to perform exam, if SANE provider not available at presenting hospital
    2. Exam is typically performed within 96 hours of assault (varies by U.S. state)
      1. In rare cases, may be performed up to 5-7 days following assault (accuracy diminishes with time)
    3. Forensic evidence from oral or anal penetration collected within 24-36 hours (72 hours in children)
    4. Patients may consent or decline to each part of the evaluation (exam, photos, evidence collection)
    5. Up to 8 sterile saline swabs from mouth, neck, Breast, nipple, penis, Scrotum, perineum and anus/Rectum
      1. Woods lamp is ineffective at identifying semen
      2. UV alternative light sources (e.g. Bluemaxx BM500) may be used to highlight additional evidence areas
        1. Saliva, semen and urine (as well as soap and lotion) fluoresce or glow under ultraviolet light
        2. Nelson (2002) Acad Emerg Med 9:1045-8
      3. Toluidine blue may also help identify sites of injury
        1. Hochmeister (1997) J Forensic Sci 42(2): 316-9 [PubMed]
    6. Anal swabs
      1. Anal swabs are obtained by blind sweep at a point approximately 2 cm within the Rectum
    7. Anoscopy (indicated only as indicated for lesions, injury)
      1. Toluidine Blue dye may be used to highlight Lacerations and tears near the anus
      2. More extensive evaluation and possible repair by general surgery under Anesthesia may be needed
    8. Toxicology Screening
      1. Screen for substances used in Alcohol and Drug Facilitated Sexual Assault (ADFSA)
      2. Toxicology specimens may be obtained up to 96 hours after assault
  4. 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. Hepatitis B Vaccine (HepB Immunoglobulin is not recommended)
    4. Tetanus Prophylaxis (if oudated)
  5. Consider HIV Prophylaxis in high risk exposure
    1. See HIV Postexposure Prophylaxis
    2. Assess HIV risk in assailant
    3. Receptive anal intercourse has the highest HIV Transmission risk
    4. Consider contacting National Clinician's Post-exposure Prophylaxis hotline (PEPline) at 888-448-4911
    5. Follow-up required in 7 days if prophylaxis started
  6. Disposition
    1. Rape crisis center
    2. Consider mental health counseling (after initial follow-up)
      1. Mood Disorders and Alcohol Abuse are very common after rape

VII. Resources

  1. CDC Sexual Violence Data
    1. https://www.cdc.gov/violenceprevention/sexualviolence/datasources.html

VIII. References

  1. Arne Graff, MD (2018) Email Communication
  2. Riviello (2017) Crit Dec Emerg Med 31(3): 3-10
  3. McLean (2013) Best Pract Res Clin Obstet Gynaecol 27(1): 39-46 [PubMed]

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