Chapter 293: Female and Male Sexual Assault

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.

Sexual assault nurse examiners (SANEs) provide expert assistance for sexual assault evaluation. SANEs are certified by examination through the Commission for Forensic Nursing Certification. Requirements before examination include an unrestricted RN license, 2 years of nursing experience, 40 hours of coursework, and competency in supervised sexual assault examination.¹⁴ Physicians, physician assistants, and nurses can also complete a separate course of training and receive certification as a sexual assault forensic examiner (SAFE). The Department of Justice established national training standards for SAFEs in 2006.¹⁵ Individuals, most often physicians and physician assistants, who complete the proscribed training and pass a standardized exam receive certification as a SAFE. There is little difference between SANE and SAFE training, but only registered nurses are eligible to train as SANEs, and the Commission for Forensic Nursing maintains authority over the certification of SANEs.

Because SAFEs and SANEs are specially trained to perform the precise and sensitive history, physical, and forensic examination, and preserve evidence in a chain of custody, many U.S. hospitals have designated these individuals as part of sexual assault treatment teams (SARTs). Local EMS personnel can transport survivors of sexual assault to SARTs as a matter of protocol.

CULTURAL DIFFERENCES AND MINORITIES

Appropriate cultural competency skills often set the tone for the first steps toward healing. Some cultures consider rape a punishment or a consequence of aberrant sexual behavior.¹⁶ Societies characterized by gender-based power disparities are often less likely to define sexual coercion and threats of violence as rape. Women from such cultures often present for care with other chief complaints or will give inconsistent histories if they feel they are culpable or could have offered more resistance.¹⁷ In countries with a history of slavery, indentured servitude, human property laws, and rigid caste or class systems, policies, traditions, and biases affect the treatment and adjudication of sexual assault. Survivors may be reluctant to report victimization if they fear a biased criminal justice system, do not think police will help, or anticipate being blamed by their family or community.^9,18,19

Fear of deportation may impact the decision of illegal aliens regarding evidence collection, police reporting, and testifying in court. Before encouraging patients to make a police report, learn your state's laws about illegal aliens who are crime victims.

Women of color face more challenges than white women obtaining assistance after rape. Services for victims of diverse backgrounds are limited, and minority victims are often reluctant to contact rape crisis centers.⁹ Although most large cities have good referral services and resources for providers, smaller communities may not have support services for minority and ethnically diverse patients. For black women survivors of sexual assault, poverty is a positive predictor of increased life-long risk of depression and posttraumatic stress disorder.^9,20,21 The Substance Abuse and Mental Health Services Administration National Council for Trauma-Informed Care provides excellent resources for institutions, providers, and patients,²² especially for referrals for continuing care.

TRIAGE

Triage sexual assault patients as a high priority, in accordance with Department of Justice recommendations.¹³ Notify the SAFE or SANE on call, and place the patient in a private room, ideally one reserved for the care of sexual assault victims. If a SAFE or SANE examiner is not in-house or if the hospital does not have a SART program, the triage nurse should notify the emergency physician of the patient's presence in the department. Make sure the patient does not undress or change into a hospital gown, as all clothing must be properly removed and stored for forensic evaluation. Tell the patient not to wash, drink, or rinse the mouth. Provide appropriate medical care whether or not patients agree to evidence collection, police reporting, or assisting with criminal prosecution.

HISTORY

Begin the interview with introductions, express regret about the assault, and provide reassurance that medical and psychological needs will be addressed. Maintain a professional, caring attitude. A patient's response is affected by the physician's attitude. A physician's shock or outrage may increase the patient's concern about physical injuries or cause her to feel marginalized. Questions perceived as critical or judgmental result in feelings of guilt and shame and interfere with the survivor's ability to provide a thorough history. Calm reassurance will facilitate the history, examination, and collection of evidence.

Ask open-ended questions about sexual history. For some women, sexual assault is the first sexual encounter, and for some lesbian patients, it may be the first sexual encounter with a male.

Obtain a thorough past medical history and general assault description, and ask the patient about injuries. In some instances, the triage nurse will have obtained the past medical history. In EDs with SANE services, a detailed assault history, to help guide the evidentiary examination, will be obtained by the SANE. If there are no SANE services, but a sexual assault advocate, police representative, or social worker is available, have those individuals in the room during the history taking so that the patient does not have to repeat information.

Details to gather about the assault and medical history are listed in Tables 293-1 and 293-2. Most authorities caution that the chances of finding forensic evidence >72 hours after the assault are slim, so a forensic examination is not necessary if >72 hours have elapsed since the assault, unless the specific state allows evidence collection up to 96 hours after the assault. Verify the policy in your state well in advance of the need to know.

CONSENT FOR FORENSIC EXAMINATION

Have the patient sign the consent form for the forensic examination, collection of evidence, photography, and transfer of evidence to law enforcement authorities. Most hospitals have a prepackaged rape kit with equipment and directions. However, check with the police if you are unsure about the utility of your hospital's kit, because some police departments may require use of a specific kit for their precincts. Hospitals will usually allow the storage of a rape kit for a specified period of time while the patient decides whether or not she wishes to make a police report. In such a case, encourage the patient to consent to the forensic exam. Not every part of the forensic evidence kit needs to be used every time. Tailor the collection of evidence to the specifics of the assault.

If >72 hours (or 96 hours, according to your hospital's policy) have elapsed or the patient does not want an evidentiary examination, still perform a full history and physical examination, provide pregnancy and sexually transmitted disease prophylaxis, and refer for follow-up medical care and rape crisis counseling.

PHYSICAL EXAMINATION

General Examination Record general information such as vital sign values and alertness and orientation. After clothing is properly removed and stored, perform a head-to-toe inspection, and look for injuries. Focus on defensive injury areas such as the extremities, and carefully check potential areas of injury such as the oral cavity, strangulation signs at the neck, breasts, thighs, and buttocks. Describe all injuries, and record all areas of tenderness, even if there is no outward sign of injury. Injuries, predominantly bruises, are often located on limbs (32%), face (23%), and torso (7%), with most assault survivors sustaining light (44%) or moderate (18%) injuries.²³ Other nongenital injuries include abrasions (40%), lacerations (4%), and bites and burns (1%).¹⁰

FORENSIC EXAMINATION

The forensic examination includes collection of head and pubic hair and buccal swabs for DNA comparison, photographs of injuries, and vaginal and perineal examination, often with colposcopy. Tell the patient what the examiner is doing at each stage of the process. Tell the patient she can take a break at any point during the examination.

Assemble all of the needed equipment for forensic examination. Throughout the examination, keep the patient's body covered as much as possible. Have several pairs of gloves available for different parts of the examination—change gloves between the physical and the genital exam, and again between the genital and the anal exam. A detailed list of equipment and a demonstration of the examination and evidence collection is available. Take photographs of abrasions, bruises, contusions, lacerations, bite marks, burns, areas of erythema, hematomas, incisions, petechiae, and swelling. Document location, position of patient, and position of injury, using a clock face reference. Traditionally, when the patient is in lithotomy position, the pubic bone is at 12 o'clock, the left hip is at 3 o'clock, and the right hip is at 9 o'clock. Begin the photographic series with a photograph of the patient's face and end with a photograph of the patient's hospital wrist band. If photography is not available, describe signs of trauma and areas of tenderness in detail using a body map.

Begin the genital exam with combing of the pubic hair and extraction of hair samples. Patients can pluck their own hair, but make sure that the hair root is included. Examine the genital and rectal areas for injuries and signs of trauma. Note any vaginal discharge, vaginal abrasions, cervical abrasions, and cervical lacerations. In some institutions, a topical application of toluidine blue dye is used to highlight microtrauma. Toluidine is a dye with affinity for DNA and RNA.²⁴ When placed on an area where the topical nonnuclear layer has been removed (as by abrading by injury), toluidine dye will be taken up by underlying cellular tissue. It is typically mixed for use by the hospital pharmacy. Toluidine is applied to the external vulva, especially the posterior fourchette, but not onto mucous membranes. If toluidine dye is used, do not perform a speculum examination until after the toluidine dye examination is completed, because the speculum examination itself may induce small abrasions that can be confused with injuries from the assault.²⁵ After examination, remove excess dye with a water-soluble lubricant. If the solution is not used soon after it is mixed, cover the bottle with aluminum foil, store at 4°C (39.2°F), and bring to room temperature before use.²⁶ An alternative to bottles of toluidine blue dye is the commercially available Forensic Blue Swabs^®.

Colposcopy detects injuries not visible to the naked eye.¹¹ In one study, only 34% of genital lesions were seen with the naked eye, 49% were seen with a colonoscopy, and 52% were seen with toluidine blue dye.²⁵ If the colposcope is used to photograph injuries, document magnification. If the patient reports anal penetration, examine the anus and rectum for abrasions or lacerations.

Finally, darken the room and scan the entire body surface with a Woods lamp to detect traces of semen. Swab areas where the perpetrator made any oral contact, and swab areas that illuminate with the Woods lamp. Dry and label all swabs and add to the rape kit.

After all evidence is collected, make sure to maintain chain of custody. Do not leave the kit unattended. Each party that releases and accepts the evidence kit must sign, date, and time the chain of evidence form. If the police are not present to receive the evidence, store the kit in a locked cabinet specifically designated for this purpose. Many rape kits contain elements which require refrigeration. In this case, when police are not available to accept the kit, store the entire kit in a locked refrigerator only used to store rape kits.

LABORATORY TESTING

Obtain ancillary tests as clinically indicated. If there is high suspicion of drug-facilitated rape, a urine sample can be sent to a laboratory for toxicologic testing. Drugs that are typically thought of as "date rape" drugs, such as ketamine, Rohypnol, and gamma hydroxybutyric acid (GHB), are not detected on routine ED toxicology screening tests, and special "send out" tests must be ordered. Rohypnol can be detected in the urine for up to 72 hours, and GHB can be detected for 12 hours. Results, however, are not available for days.²⁷ Most SANEs typically send these tests when indicated and assume responsibility for checking the results. In some hospitals with SART programs, consent forms give the right to the prosecuting attorney in the Special Victims Unit to receive the results. If these "send out" tests are ordered by the ED physician, develop a protocol for checking results and documenting results in the patient's record. Guidance for appropriate ordering can be obtained from womenshealth.gov or by calling 800-994-9662.

Obtain a urine or serum pregnancy test before giving emergency contraception. Testing for gonorrhea, chlamydia, and bacterial vaginosis is not necessary, because treatment is provided at the ED encounter. However, do test for syphilis, hepatitis B and C, and human immunodeficiency virus (HIV). Obtain serum chemistry, liver function studies, and CBC for patients who will receive HIV postexposure prophylaxis (PEP).²⁸ Follow baseline HIV testing with repeat testing at 6 weeks and 3 and 6 months.

Follow standard care protocols and also individually assess the needs of the survivor.^29,30 Treat physical injuries and provide immediate crisis intervention if needed. Offer emergency contraception, sexually transmitted disease prophylaxis, tetanus and hepatitis B vaccination if needed, and prophylaxis against HIV infection (Table 293-3).²⁸

SEXUALLY TRANSMITTED INFECTION PROPHYLAXIS

The prevalence of sexually transmitted infections in an adolescent urban population varies as follows by causative organism: Neisseria gonorrhoeae, 0.0% to 26.3%; Chlamydia trachomatis, 3.9% to 17%; Treponema pallidum, 0.0% to 5.6%; Trichomonas vaginalis, 0.0% to 19.0%; and human papillomavirus, 0.6% to 2.3%.³¹ The regimens currently recommended by the Centers for Disease Control and Prevention are provided in Table 293-4.

EMERGENCY CONTRACEPTION

Obtain a pregnancy test on all women unless there is a history of hysterectomy. Offer pregnancy prevention to those who are not pregnant.^{32,33,34,35,36,37} Also prescribe an antiemetic for nausea and vomiting.^36,37 Offer meclizine 50 milligrams, metoclopramide 10 milligrams, or ondansetron 4 milligrams.³⁷ Three common emergency contraceptive regimens are listed in Table 293-5. A fourth method of emergency contraception recommended by the Centers for Disease Control and Prevention but not commonly used after sexual assault or in the ED is the insertion of a copper intrauterine device. Provide emergency contraception as soon as possible following exposure; the Centers for Disease Control and Prevention states it can be provided within 5 days of unprotected intercourse.³⁸ Pregnancy after emergency contraception is 3.6 times more likely for obese women than for women with a normal body mass index. Failure of emergency contraception is more likely to occur with levonorgestrel than with ulipristal acetate; however, in all women, regardless of body mass index, the most significant factor predicting failure is the cycle day of intercourse.³⁹ Because rape poses a risk of sexual disease transmission and because rape may have resulted in trauma, oral contraceptive pills are the preferred form of ongoing contraception.

Breastfeeding is not contraindicated following emergency contraception. Advise women that emergency contraception does not protect against HIV infection, other sexually transmitted infections, or subsequent unprotected intercourse. Recommend follow-up with a healthcare provider for all women and especially those with abnormal bleeding after cessation of emergency contraception.³⁷ Advise women who use emergency contraception to follow up with a regular provider to begin use of ongoing contraception in the form of oral contraception pills or copper intrauterine device to ensure successful prevention of pregnancy from subsequent unprotected intercourse.^38,39

HIV POSTEXPOSURE PROPHYLAXIS

Viral load in the assailant is the most significant factor determining infectivity.⁴¹ HIV seroconversion has occurred in persons whose only known risk factor was sexual assault or sexual abuse.⁴² HIV transmission risk increases when bleeding occurs with vaginal, anal, or oral penetration; if viral load in the ejaculate is high; and if genital lesions are present in the assailant or the survivor.²⁸ Assistance in determining the advisability for PEP can be obtained by calling the toll-free 24-hour National HIV/AIDS Post Exposure Hotline at 1-888-448-4911 or by accessing their website at www.nccc.ucsf.edu/home. The Centers for Disease Control and Prevention recommendations for postexposure assessment of adolescents and adults are listed in Table 293-6.

If PEP is administered, follow the standard protocol recommended by your hospital's infectious disease specialists. When prescribing HIV PEP, ask about sulfa allergy. Truvada includes tenofovir which has a sulfa moiety.

Excellent care for survivors of sexual assault requires the coordination of clinical medicine with forensic science, law enforcement, and survivor advocacy. Once injuries are assessed and managed, offer counseling. This can be done by a dedicated rape counselor or trained social worker. If injuries are not severe, a rape counselor may be present prior to the physician's assessment. Gaps in service and patient care have largely involved lack of treatment of sexually transmitted infections and lack of availability of pregnancy-related services.⁴³

Prior to discharge, make sure that the patient has a safe place to go, a safe way to get there, and a plan for addressing absence from home or work. This conversation should include a discussion of if, to whom, and how she will reveal her assault for the present time. Cultural competency of the caregivers is essential throughout the delivery of healthcare services to the survivors of sexual assault, but is critical at this juncture. If the team is not familiar with the cultural attitudes and practices surrounding sexual assault in the survivor's religious, ethnic, or social group, ask the patient how his or her family, religious community, or social network may respond.

Prior to discharge, provide the opportunity for bathing and oral care. Because clothing has been sequestered as part of the evidence kit, hospitals should provide fresh, packaged underwear and outerwear for the patient. Sweat suits are customarily provided at most SART hospitals. This is an appropriate time to raise the issue of returning to the home environment, since the patient will return in clothing that is not customary dress. Provide a headscarf for women who customarily wear head coverings in public.

Arrange follow-up appointments according to Centers for Disease Control and Prevention recommendations. Patients receiving PEP should be seen in 3 to 7 days following initial assessment, and all patients should be seen in 1 to 2 weeks.²⁸ This ensures the effectiveness of pregnancy prophylaxis and sexually transmitted infection treatment.

Male sexual assault survivors should follow up with a urologist or proctologist. Special populations, such as children, should be referred to a pediatrician or a pediatric abuse clinic.

ADOLESCENTS AND CHILDREN

Consider sexual abuse in children if no definitive explanation for nonsexual transmission of a sexually transmitted infection can be identified.²⁸ For extensive discussion, see chapter 148, "Child Abuse and Neglect." The most experienced examiner available should examine children to minimize pain or further trauma. Today, there are over 600 pediatric SANE programs in the United States.^44,45,46

ELDERLY PATIENTS

Most elder assaults take place at the patient's home, and most assaults are by an unknown assailant.⁴⁷ In the case of an elderly assault survivor, the forensic interview and examination present unique challenges. The patient not only may resist the pelvic examination because of injury or pain, but the pelvic area may be difficult to visualize because of hip contractures or vaginal atrophy. It is also difficult to explain the examination to a patient with dementia or cognitive impairment. Further challenges include obtaining an accurate and reliable history of the details of the assault, the injuries sustained, and regions of pain or discomfort.^47,48 Special adjustments may be needed for the interview and sexual assault examination.^47,48

TRANSGENDER AND LESBIAN PATIENTS

Information about sexual assault of lesbian and transgendered women has mostly relied on data from informal surveys.⁴⁹ A London clinic reported that transgender sex workers self-reported higher rates of violence and sexual assault than did biological female sex workers, but that rate was not specified.⁵⁰ FORGE (www.forge-forward.org) is a Wisconsin-based group for the support of the transgender population. The group has a Web site with prinTable handouts for lesbian and transgendered patients who are sexual assault survivors, survivor first-person narratives, and resource links for both patients and providers.

MEN

Male sexual assault is less common than sexual assault of women.⁵¹ Assaults on males generally result in more severe injuries,^52,53 with 40% to 60% of males sustaining anogenital injuries,^53,54 and assaults on men are likely to involve multiple assailants.⁵⁵ At least a third of males who are sexually assaulted have a history of psychiatric or cognitive disability.⁵⁴ One major factor that complicates the care of male survivors is the fact that physiologically, the stimulation of anal penetration can lead to involuntary erection and sometimes to ejaculation. Furthermore, many assailants manually stimulate their victims to cause ejaculation. Numerous cases of male sexual assault have been determined to be consensual by judges and defense attorneys who fail to understand the involuntary nature of this physiologic response.⁵⁵ The survivors themselves can be confused and distressed by this response and may hesitate to offer this information. Use a short, simple explanation of the physiology using lay language to assist in history taking.

Hospitals have male rape kits available, and the same guidelines should be followed for history, physical exam, collection of forensic evidence, and maintaining chain of custody as have already been described. SANEs and SAFEs are all trained in the sexual assault forensic examination of males. Resources for counseling may be more difficult to find for the male survivor, especially in small communities. The Rape, Abuse & Incest National Network does have special resources for men. Their victim hotline can be reached at 1-800-656-HOPE, and their Web site can be accessed at www.rainn.org

The American Academy of Pediatrics, American College of Obstetrics and Gynecology, American College of Emergency Physicians, and Centers for Disease Control and Prevention all have issued recommendations regarding the acute management of rape survivors.^{28,56,57,58,59} The American College of Emergency Physicians issued a policy statement on the treatment of the patient with a complaint of sexual assault.⁵⁸ As an adjunct to this policy, the American College of Emergency Physicians Emergency Medicine Practice Committee prepared a handbook, Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient, to assist in developing a community or ED plan.⁵⁹

Acknowledgment: The author would like to thank Sheryl L. Heron, MD, and Debra E. Houry, MD, for writing the prior edition of this chapter, which has been updated and revised for this edition.