Sexual Assault

Aka: Sexual Assault, Rape, Rape Management, Forcible Intercourse, Female Rape Victim, Date Rape, Alcohol and Drug Facilitated Sexual Assault, ADFSA

1. See Also
   1. Sexual Assault of Male Victim
   2. Sexual Abuse in Children
   3. Rape Kit (Sexual Assault Kit)
   4. Date Rape Drug
2. Definitions
   1. 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. Epidemiology
   1. Rape lifetime Incidence in women: 18%
   2. Most perpetrators are known to the victim (only 14% of rapes are by strangers)
4. History
   1. Use the patient's exact words
   2. Use the phrase "alleged Sexual Assault"
      1. Avoid the word "Rape" (legal term, not a medical term)
   3. Document specific details
      1. Age and other identifying details about the assailant
      2. Date, time and location of assault
      3. Specific circumstances about the assault
         1. Include sexual contact
         2. Exposure to body fluids
      4. Restaints used by the assailant (e.g. weapons, drugs)
   4. Document any cleaning (bathing, douching) or clothes changing done by patient since the assault
   5. Obtain full gynecologic history
5. Labs
   1. Forensic Evidence with Rape Kit
   2. Urine Pregnancy Test
   3. Vaginal and Endocervical Samples (consider repeating at 2 week)
      1. Gonorrhea PCR
      2. Chlamydia PCR
      3. Trichomonas
      4. Wet prep for sperm (motile for up to 6 hours)
      5. Consider Herpes Simplex Virus Testing to obtain baseline
   4. Serology initially and at 6, 12 and 24 weeks
      1. Hepatitis B Surface Antigen and Hepatitis B core IgM
      2. RPR for Syphilis Testing
      3. HIV Test
6. 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. Emergency Contraception
      1. Levonorgestrel 1.5 mg for 1 dose (Plan B)
   3. STD Prevention (perform all measures)
      1. Ceftriaxone 250 mg IM for 1 dose
      2. Metronidazole 2 g orally for 1 dose
      3. Azithromycin 1 g orally for 1 dose (or Doxycycline 100 mg twice daily for 7 days)
      4. Hepatitis B Vaccine
      5. CDC as of 2010 guidelines does not recommend Valacyclovir for HSV prophylaxis (insufficient evidence)
   4. 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. Follow-up required in 7 days if prophylaxis started
7. Associated Conditions: Following Assault
   1. Chronic Pelvic Pain
   2. Chronic back pain
   3. Fibromyalgia
   4. Headaches
   5. Irritable Bowel Syndrome
   6. Sexual Dysfunction
   7. Somatoform Disorder
   8. Alcohol Abuse
   9. Drug Abuse
   10. Anxiety Disorder
   11. Major Depression
   12. Eating Disorders
   13. Posttraumatic Stress Disorder
   14. Sleep disorder
8. Resources
   1. Sexual Assault Forensic Examiner technical assistance
      1. http://www.safeta.org
   2. Sexual Assault Nurse Examiners (SANE)
      1. http://www.forensicnurses.org/
9. Resources
   1. CDC Sexual Violence Data
      1. https://www.cdc.gov/violenceprevention/sexualviolence/datasources.html
10. References
    1. Luce (2010) Am Fam Physician 81(4): 489-5 [PubMed]
    2. Petter (1998) Am Fam Physician 58(4): 920-30 [PubMed]
    3. Tayara (2006) Best Pract Res Clin Obstet 20(3): 395-408 [PubMed]
    4. Welch (2007) BMJ 334(7604): 1154-8 [PubMed]