INTRODUCTION AND EPIDEMIOLOGY
Sexual assault is a crime of violence, intended to dominate and humiliate the victim through the use of intimidation and fear.1 In many parts of the world, sexual assault is a tool for oppression, a weapon of war, and an act of genocide. Psychological trauma is a universal consequence of rape and sexual assault, but the absence of physical injury does not indicate that an assault did not take place. Sexual assault remains a major public health problem throughout the world, with case rates of police-recorded incidents as high as 92.9 per 100,000 in Botswana to a first time record of 0.0 in Liechtenstein in 2010.2 In the United States, the case rate is 27.3 per 100,000,2 with nearly one in five (18.3%) women reporting being raped at some time during their lives.3
Although males are less commonly victimized, studies estimate that between 0.6% and 22.2% of males have experienced sexual assaults.4,5,6 According to the National Electronic Injury Surveillance System (NEISS), sexual assaults accounted for over 150,000 ED visits in 2001 in the United States.7 However, many sexual assault survivors do not report the assault to police or seek medical care.8 Women are likely to seek treatment earlier for more severe assaults and injuries, and they are more likely to delay seeking assistance if assaulted by a known perpetrator.8
In most cases of rape in the United States, a single assailant is involved, and most often the perpetrator is known to the victim.9 Force or coercion is used in most assaults, but a weapon is reported in only 11% of cases.3
About half of female10 and male11 assault survivors have genital or rectal trauma on examination, and about two thirds have some evidence of bruising elsewhere.10 Injuries are more often found in female patients <20 years old or >49 years old, those who have experienced anal assault, and those who present within 24 hours of assault. Survivors age 12 to 17 years were more likely to have anogenital injuries than those age 18 to 49 years.12
Care of the sexual assault victim is complex and can be time-consuming. Responsibilities include obtaining the medical and forensic history; performing and documenting results of the medical examination; collecting forensic evidence and ensuring that material follows the proper chain of custody; treating potential sexually transmitted infections; treating other acute medical problems and injuries; assessing pregnancy risk and providing treatment options; providing referral for crisis intervention and medical follow-up; coordinating care with sexual assault advocates; and testifying in court if needed.13 Although some hospitals provide sexual assault nurse examiners (see below) to aid in medical and forensic evaluation, in many institutions, emergency physicians will be expected to provide most of the care for sexual assault victims.