Sexual Assault

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

1. See Also
   1. Intimate Partner Violence
   2. Sexual Assault of Male Victim
   3. Sexual Abuse in Children
   4. Human Sex Trafficking
   5. Rape Kit (Sexual Assault Kit)
   6. Date Rape Drug
   7. Strangulation
2. 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
3. Epidemiology
   1. Sexual Violence experienced by 40% of U.S. women in their lifetime
   2. Rape lifetime Incidence in women: 18%
   3. Most perpetrators are known to the victim (as few as 14% of rapes are by strangers)
   4. Rape survivors report the crime to law enforcement in only 16-38% of cases, and to primary providers in two thirds of cases
4. 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
5. 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]
6. 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
   5. Serious injuries and life threatening conditions take priority
      1. Evaluate and manage physical and mental health emergencies first
7. 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 (or multiple assailants)
      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
8. Exam
   1. Defer medical forensic exam to Sexual Assault Examiner (e.g. SANE Nurse)
   2. Evaluate for acute medical conditions or Traumatic Injury
      1. Avoid interfering with forensic exam and preserve any evidence including all clothing
9. Signs
   1. See Strangulation Injury
   2. See Intimate Partner Violence
   3. See Child Abuse
   4. Neurologic
      1. Closed Head Injury or Concussion
   5. Neck
      1. Strangulation Injury
   6. Musculoskeletal
      1. Fractures
   7. Skin
      1. Bullet Wounds
      2. Knife Wounds
      3. Abrasions
      4. Bruises
10. Labs
    1. Forensic Evidence with Rape Kit
    2. Urine Pregnancy Test (or blood qualitative Pregnancy Test)
    3. Vaginal and Endocervical Samples (consider repeating at 2 week)
       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
    4. Serology
       1. Hepatitis B Surface Antigen
          1. On presentation and at 6 months
          2. Also consider Hepatitis B core IgM
       2. Hepatitis C
          1. On presentation and consider at 3 and 6 months (if assailant status unknown)
       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)
    5. Urine Drug Screen (within 72 hours of assault)
       1. Indicated if Date Rape Drug suspected
       2. Chloral Hydrate
       3. Gamma Hydroxybutyrate
       4. Ketamine (Ketalar)
       5. Benzodiazepines
11. 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. 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
       4. Copper-T Intrauterine Device
          1. May be inserted within 5 days of unprotected intercourse
    3. 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)
    4. 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
    5. 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
    6. 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
12. 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)
13. 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
14. Complications: Longterm Following Assault
    1. Chronic Pain
       1. Chronic Pelvic Pain
       2. Chronic back pain
       3. Fibromyalgia
       4. Headaches
       5. Irritable Bowel Syndrome
    2. Mental Health disorders
       1. Sexual Dysfunction
       2. Somatoform Disorder
       3. Alcohol Abuse
       4. Drug Abuse
       5. Anxiety Disorder
       6. Major Depression
       7. Attempted Suicide
       8. Eating Disorders
       9. Sleep disorder (Insomnia)
       10. Posttraumatic Stress Disorder (30-65% of survivors)
           1. Higher risk in ethnic minorities and military
15. Resources
    1. Sexual Assault Forensic Examiner technical assistance
       1. http://www.safeta.org
    2. Sexual Assault Nurse Examiners (SANE)
       1. http://www.forensicnurses.org/
16. 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
17. References
    1. (2019) Obstet Gynecol 133(4):e296-e302 [PubMed]
    2. Farahi (2021) Am Fam Physician 130(3): 168-76 [PubMed]
    3. Luce (2010) Am Fam Physician 81(4): 489-5 [PubMed]
    4. Petter (1998) Am Fam Physician 58(4): 920-30 [PubMed]
    5. Tayara (2006) Best Pract Res Clin Obstet 20(3): 395-408 [PubMed]
    6. Welch (2007) BMJ 334(7604): 1154-8 [PubMed]