#97023: Sexual Assault

Although victims of sexual assault are overwhelmingly adult women, the problem is encountered among persons of diverse age and gender. In 1995–1996, a national survey of 8,000 women and 8,000 men found that 1 in 6 women and 1 in 33 men had experienced an attempted or completed rape at some time in their lives [1]. One-half of the female victims reported they had been assaulted before their 18th birthday. Most rape victims indicated the assailant was someone they knew, and only 1 in 5 reported the assault to the police. Based on these data, the lifetime incidence of sexual assault in the United States was estimated to be 18% for women and 3% for men. Given the complexity of the problem and the limited methodology of reported studies, most of which were survey-based, the actual incidence is greater than indicated by these data [2].

In 2010, the Centers for Disease Control and Prevention launched the National Intimate Partner and Sexual Violence Survey (NISVS), an ongoing surveillance system that assesses sexual violence, stalking, and intimate partner violence victimization among adult women and men in the United States [37]. Sexual violence was defined as a sexual act committed or attempted by another person without freely given consent of the victim or against someone unable to consent or refuse. It includes forced or alcohol/drug facilitated penetration of a victim (rape); forced or alcohol/drug facilitated incidents in which the victim was made to penetrate a perpetrator or someone else; nonphysically pressured penetration (sexual coercion); or unwanted sexual touching [38].

The 2015 NISVS report (published in 2018) presented key findings [37]. With respect to sexual violence of women in the United States, the analysis showed:

With respect to sexual violence perpetrated against men, the 2015 NISVS report found [37]:

Among female victims of completed or attempted rape, 81% reported that it first occurred prior to 25 years of age, with 43% reporting that their first victimization occurred prior to 18 years of age. Among male victims of completed or attempted rape, 71% reported that their first experience occurred prior to 25 years of age, with 51% reporting that the initial incident occurred before 18 years of age [37].

Sexual violence disproportionately affects some groups. Women and racial/ethnic minority groups experience higher rates of sexual violence. According to CDC surveillance, more than 2 in 5 non-Hispanic American Indian or Alaska Native and non-Hispanic multiracial women have reported being raped in their lifetime [47]. Most victims of sexual assault are young, and population groups at increased risk include mistreated children and adolescents, college students, the mentally disabled, the homeless, and persons who are gay, lesbian, bisexual, or transgender [3,4]. Victimization of college students, often perpetrated by an acquaintance and frequently associated with the heavy use of alcohol by both victim and assailant, has become a national problem and public health concern [5].

Reporting of a sexual assault by the victim to the police or other authorities varies with the age of the victim, social context of the assault event, whether a relationship exists between victim and assailant, and the extent of injury. Assaults upon older women occurring in an unfamiliar place, perpetrated by a stranger or resulting in physical injury to the victim are most likely to be reported. Assaults perpetrated by an acquaintance, friend, or relative often go unreported to the police or other law enforcement official [33].

Among college women, the rate of reporting sexual victimization is low. It is estimated that more than 85% of rapes and attempted sexual assaults and nearly all (90%) other forms of unwanted sexual contact are unreported to the police or any campus official [31,33]. The common reasons given for unwillingness to disclose sexual victimization are self-blame (especially if victims were under the influence of alcohol), knowing the assailant and fearing reprisal, embarrassment, and the desire to avoid stigma. Although unwilling to inform police or campus authorities, most college students victimized by sexual assault do confide in a friend, relative, authority figure, or health professional [33].

In a national study involving 2,000 college women, only 27 of 230 (11.5%) rape victims reported the assault to law enforcement officials [34]. When analyzed according to type of completed assault, 16.0% of forcible rapes and 2.7% of incapacitated-alcohol/drug-facilitated assaults were ever reported to authorities. Minority status (i.e., non-White race) was associated with lower likelihood of reporting, whereas sustaining injuries during the rape was associated with increased likelihood of reporting. Of those who reported the assault, 51.9% received medical attention and 44.4% sought help from an agency that assists victims of a crime (e.g. rape crisis center). In contrast, only 13.9% of those who failed to report the assault received medical care and/or other forms of victim assistance [34].

Victims of sexual assault are most likely to present to hospital emergency departments (EDs), public health and gynecology clinics, college infirmaries, and primary care offices. Published clinical series from urban EDs have helped define the scope and character of sexual assault injury [7,8,9]. Based on these clinical reports, it may be seen that victims of sexual assault presenting to an ED are predominantly female, relatively young, often know their assailant, and are likely to have been threatened with violence and to show physical signs of trauma.

In one such study of 1,076 cases seen between 1992 and 1995, the age of victims ranged from 1 to 86 years (half were younger than 26 years of age) and 96% were women [7]. In 60% of cases, the assailant was someone known to the victim. Force was used in 80% and a weapon was present in 27% of incidents. Vaginal penetration was documented in 83% of cases, oral assault in 25%, and anal penetration in 17%. Signs of genital trauma were evident in 53% of cases, and extra-genital trauma was noted in 67% of victims. Similar results were found in an ED study of 1,100 patients published in 2009. In this study, 92% of victims were female, and the median age was 27 years. Most victims (57%) knew their assailant. Threat of force was used in 72% of cases, and physical trauma was evident in 52% of victims [8]. Alcohol consumption or drug use was involved in 54% of these assaults.

The impact of sexual assault leads to immediate and long-term physical and mental health consequences. In addition to the potential risk for acquiring an STI, approximately 1% to 5% of rape victims become pregnant [10]. The National Violence Against Women Survey (NVAWS) found that 33% of women and 24% of men received counseling from a mental health professional as a direct result of their last assault; 28% and 10%, respectively, lost time from work [1]. Survivors of assault often suffer from post-traumatic stress disorder, and many experience recurring reproductive, gastrointestinal, cardiovascular, and sexual health problems [47]. Sexual assault is also linked to negative health behaviors, including substance abuse, risky sexual activity, and increased risk for re-victimization.

The initial clinical assessment includes a careful history and physical examination, followed by selected laboratory testing and radiographic studies as indicated by clinical findings. Physical signs of bodily injury are present in more than half of all persons examined after sexual assault, and virtually all patients will appear emotionally distraught, embarrassed, and fearful [7,8]. Specific needs to be addressed include general medical care and assessment of injury, an explanation of all facets of the clinical and forensic evaluation, a description of options for care, and provision of support for patient and family. Cases of sexual assault also carry the parallel consideration of potential criminal prosecution of the assailant and thus the need to inform authorities and to collect and preserve evidence.

Patients who present within the legal time frame for evidence collection should be referred for evaluation by an ED or treatment center with resources and staff trained for this purpose. The specified time limit varies among states and municipalities, usually ranging from 72 to 120 hours. Clinical care providers should inform themselves as to the time frame within their own jurisdiction. Where possible, the evaluation should be conducted by a multidisciplinary team that includes an emergency medicine physician, a trained nurse examiner (i.e., SANE), and a rape crisis counselor or social worker. The patient should be offered a formal forensic examination. This is optional and requires informed consent. The general approach to the history and physical examination is outlined in the following sections, followed by an expanded, detailed review of the principles that pertain to the forensic evaluation.

In the multicultural landscape of the United States today, interpreters are a valuable resource to help bridge the communication and cultural gaps between clients/patients and practitioners. If a patient has limited English proficiency, a medical interpreter (live or over the phone) should be accessed. Due to the sensitive nature of the evaluation, some patients will be embarrassed to discuss the matter with a third party. Even if an interpreter is initially declined by the patient, continue to assess the necessity of interpretation assistance. Family members are not considered appropriate interpreters.

Nursing staff in EDs and clinics are often the first to interact with assault victims and their families. The ability to quickly recognize forensic issues, and thus direct the subsequent course of the evaluation, is a valuable skill to possess [14,15]. Although lifesaving measures take priority over considerations of evidence preservation, it should be recognized that quality of life could be significantly impacted for those whose assailant is not brought to justice.

Accurate and thorough forensic evidence is crucial to the successful arrest and prosecution of a criminal assailant. Evidence of the use of force and the assailant's identity and possible ties to the victim should be gathered to aid law enforcement in their investigation. It is essential that evidence remains intact as much as possible until proper collection and documentation is completed. It is equally important to accurately record all statements made by the victim, regardless of its seeming pertinence to his or her medical care. Evidence that is improperly collected by untrained individuals, destroyed or mishandled during the course of treatment (e.g., contamination, using wound sites for drainage), or not followed in the chain of custody may be of limited value to law enforcement and justice officials.

The first step in preserving evidence is identifying the precise nature of the assault, circumstances, and scope of injury to the victim. This helps to determine the direction of the investigation and the type of forensic evidence to be obtained during the clinical and forensic evaluation. The time of the assault and the sequence of events following should be ascertained, as the quality of evidence often deteriorates over time. For example, DNA in saliva deteriorates especially rapidly, often in less than 48 hours. It is recommended that a sexual assault forensic exam be administered within 96 hours of an attack for the collection of trace evidence; however, bruises, bite marks, and other injuries are often still evident beyond this time frame [16,17].

Any article or remnant of clothing worn by a victim or assailant at the time of the assault is considered important forensic evidence and should be preserved in transit. Each item should be placed in an individual evidence bag for forensic study by a law enforcement criminalist. An able patient needing to disrobe should do so over a drop sheet, which is then bound and labeled, in order to collect all traces of evidence. Upon arrival, whether by car or ambulance, the attempt should be made to locate all items of clothing. Emergency transport personnel should be able to account for this, but in their absence, the forensic team should identify and arrange to retrieve any relevant articles of clothing. Any tears or cuts to clothing made during treatment should be documented. Clothing removed in the ED must be recovered. If patients have changed clothing, the fresh clothing nearest the attack site (generally underwear or other undergarments) should be collected and examined as evidence.

Care should be taken to assure that the patient's skin remains unwashed until after examination and evidence collection is completed, because the skin often holds much of the most vital evidence for medical-forensic purposes. Contamination of evidence and swab specimens can be avoided by wearing appropriate protective equipment, handling as little as possible, and avoiding sneezing and/or coughing over samples. Forensic examiners should wear surgical masks during evidence collection, and gloves should be changed frequently.

In cases of food, beverage, and drug poisoning or tampering, vomitus is considered evidence and should not be discarded. In fact, whenever a forensic patient is vomiting, a sample should be collected and retained to determine if he or she has been the victim of poisoning. In certain instances, stool and urine samples should also be collected.

In the case of sexual assault, a determination should be made as to whether the assault has been reported to the police and whether representatives of law enforcement have already initiated an evaluation. If not, healthcare professionals have the duty to report cases of assault/abuse to officials. If law enforcement has already been involved, certain questions that could cause undue stress may be avoided during the examination (e.g., a description of the suspect); however, certain questions that pertain to the medical-forensic exam should be addressed. Questions that will have been asked by investigators include [18]:

Questions pertaining to the medical-forensic exam include the last six on this list, as these serve to focus the physical exam and the search for evidence. If ejaculation took place, this location should be identified; however, other fluids, such as blood and saliva, are also useful for DNA collection. If there were multiple assailants, the patient should be encouraged to identify which assailant committed which act(s). The account should include all violence performed and/or threatened and should conclude by asking if there were any other acts performed that were not already covered.

Recent consensual sexual activity should be identified, along with information about what the patient did after the attack. Many women wipe their vulva with towels or toilet paper, and some may douche; this information should be noted so these items can be recovered for DNA testing. Tampons removed or inserted post-assault should also be recovered.

Sexual assaults are particularly difficult to discuss, but it is necessary to systematically explore several lines of questioning in order to assure a complete and accurate description of the assault. This will greatly aid both the collection of forensic evidence and the eventual prosecution of the suspect(s) for each violation. For example, an assailant can be convicted of attempted sodomy even if the act did not result in actual penetration. Therefore, a comprehensive list of possible sexual/violent acts should be discussed, each with its own specific question. There are four possible answers to every question: yes, no, attempted, and unsure [19]. Sample questions would read as follows:

Or, conversely:

This line of questioning should continue until a very detailed description of the assault is documented; many jurisdictions use a locally standardized form for this task. It is important to remember that informed, written, and signed consent by the patient (or parent/legal guardian, where applicable) is required for a formal forensic evaluation. A provision for consent may be included in the forensic report paperwork. The U.S. Department of Defense Sexual Assault Forensic Examination Report is a good example of a federally standardized, complete form that incorporates a consent provision. It may be accessed online at https://www.sapr.mil/public/docs/miscellaneous/toolkit/dd2911__Sept_2015.pdf [19].

Examination of the patient should be conducted in a thorough head-to-toe manner, with the intent of documenting every indication of injury related to the incident (no matter how insignificant and involving every part of the body) using a body-map or wound chart. The entire body surface should be inspected and palpitated to identify areas of bruising and injury to muscle and bone. As evidence is detected during the examination, it should be collected, documented, and preserved [15]. Information gathered from transport personnel and during the forensic interview helps to identify areas requiring careful attention, but this should not detract from conducting a thorough examination.

An important component of the physical examination/interview is the patient's general appearance and demeanor upon presentation [15]. This should be recorded as objectively and with as much description as possible in a few sentences. The ability of the patient to remember details of the incident and to cooperate with the exam should be noted.

The infections commonly reported in women after sexual assault are chlamydia, gonorrhea, trichomoniasis, bacterial vaginitis, and pelvic inflammatory disease (PID) [21]. The possible exposure to hepatitis B virus and human immunodeficiency virus (HIV) is also an important consideration. In general, the risk of infection is relatively low; published estimates are 3% to 16% for chlamydia, 7% for trichomoniasis, and 11% for PID [20]. The risk, however, does vary directly with the degree of genital trauma, associated bleeding (sustained by the victim or assailant), and the number of assailants. The Centers for Disease Control and Prevention (CDC) has published guidelines for the assessment, counseling, and preventive treatment of infection following sexual assault, including common pelvic infections, hepatitis B, human papilloma virus (HPV), and HIV [21].

Although HIV transmission after sexual assault has been reported, there are no epidemiologic data upon which to estimate risk from assault by an unknown assailant. In the context of consensual sex, the risk following a single exposure (vaginal intercourse) is estimated to be 0.1% to 0.2% for vaginal intercourse and 0.5% to 3% for receptive anal intercourse [21,22]. While the overall risk of acquiring HIV after a rape event is likely to be low, this risk may be substantially greater under certain circumstances, including:

Testing for sexually transmitted infection during the acute evaluation phase is of limited value and may be deferred until later. In selected cases, the decision to administer antimicrobial prophylaxis may obviate the need for testing. Table 1 provides a suggested approach to testing, derived from the CDC's 2021 guidelines [21]. The initial examination includes testing of cervical/vaginal secretions (or other sites of penetration) for chlamydia and gonorrhea by nucleic acid amplification test (NAAT) and for trichomoniasis by vaginal swab wet mount examination and/or NAAT from specimens of urine or vaginal secretions. Serum serologic testing for hepatitis B, syphilis, and HIV should also be considered.

The CDC recommends HIV screening of sexual assault patients after the patient has been informed and unless the patient declines [21]. Some states stipulate that HIV testing must be coupled with mandatory counseling and follow-up care. The policy and guidelines should be worked out in advance within each locale and jurisdiction, in accordance with prevailing law and established guidelines.

Testing for HIV in the immediate post-assault period has limited utility, as it will not confirm or exclude exposure, nor will it indicate whether the victim is likely to become infected [22]. For purposes of later criminal or civil action, the patient may wish to have baseline testing to demonstrate absence of prior infection. Thus, the option for confidential, anonymous baseline testing should be offered and discussed.

If the latent infection status of the assailant is unknown, routine postexposure hepatitis B vaccination is adequate, without the need for specific immune globulin (HBIG). If the assailant is known to be hepatitis B positive, HBIG should be added. To complete the hepatitis B vaccine series, follow-up doses of vaccine should be scheduled for 1-2 and 4-6 months after the initial dose [21]. Survivors previously vaccinated who did not receive postvaccination testing should receive a single booster dose.

Victims of rape are also at risk for acquiring HPV infection. Post-exposure administration of HPV vaccine is effective in preventing primary infection and other HPV-associated diseases, including cancers. HPV vaccination is recommended for both female and male sexual assault survivors 9 to 26 years of age who have not been vaccinated or are incompletely vaccinated [21]. The vaccine should be administered to sexual assault survivors at the time of initial examination, and follow-up doses should be given at one to two months and six months after the first dose. A two-dose schedule (0 and 6 to 12 months) is recommended for persons initiating vaccination before age 15 years [21].

The possibility of HIV exposure should be assessed at the time of the initial evaluation of a sexual assault victim. Despite the low risk of HIV transmission, most clinicians and other healthcare professionals experienced in the care of sexual assault patients believe that postexposure prophylaxis (PEP) should be offered in nearly all cases. The CDC guidelines recommend a 28-day course of highly active antiretroviral therapy (HAART), initiated within 72 hours of exposure [21]. Available data indicate that the effectiveness of HAART falls off if initiated beyond 72 hours of exposure, at which point the risk/benefit ratio begins to favor omitting PEP. Thus, antiretroviral therapy should be started as soon as possible after the assault, ideally within 4 hours, and probably should not be initiated if greater than 72 hours have elapsed. Other information that impacts the decision to initiate PEP includes knowledge of the assailant's HIV status or prior risk behaviors (e.g. injection drug use), whether there was vaginal or anal penetration, evidence of ejaculation on mucosal surfaces, the character and extent of injury, and whether multiple assailants were involved. It is recommended that the decision and choice of antiviral therapy be made in consultation with an infectious disease specialist or other healthcare professional familiar with the most current PEP guidelines. Assistance with PEP-related decisions can be obtained by calling the National Clinician's Post Exposure Prophylaxis Hotline (PEP Line) at (888) 448-4911.

Follow-up less than one week after the initial evaluation provides the opportunity to review previous test results, complete an assessment for STIs, and ensure safety and adherence to prescribed medication. CDC guidelines advise that a follow-up examination at one to two months should be considered to re-evaluate for development of anogenital warts, especially in patients who received a diagnosis of other STIs following the assault. If initial tests were negative and infection in the assailant cannot be ruled out, serologic tests for syphilis can be repeated at four to six weeks and three months; HIV testing can be repeated at six weeks and at three months using methods to identify acute HIV infection [21].

In the aftermath of sexual assault, a variety of chronic somatic, cognitive, and emotional sequelae have been observed in sexual assault victims (Table 3). The individual's response and subsequent ability to cope with the trauma of the assault are influenced by several related factors. These include the nature and severity of the assault itself, age of the victim, relationship between the victim and assailant, prior history of abuse, and the person's own ambient life stress and coping mechanisms. For some, the impact of a sexual assault experience is severe and long-lasting, often resulting in difficulty with interpersonal relationships and tasks of daily living, sexual dysfunction, loss of worktime, and increased utilization of healthcare resources [25,26,27].

A meta-analysis of clinical studies published between 1980 and 2002 revealed a significant association between prior sexual assault and the lifetime diagnosis of fibromyalgia, chronic pelvic pain, and functional gastrointestinal disorders [28]. In a cross-sectional, randomly selected study of 219 women followed in a Veterans Administration (VA) primary care clinic, a history of prior sexual assault was found to be associated with a significant increase in somatization scores, multisystem physical complaints, anxiety, work absenteeism, and health care utilization [29]. Among another cohort of women receiving VA medical and mental health care, the prevalence of post-traumatic stress disorder was found to be 7 to 9 times higher in women who had experienced a prior sexual assault, compared with those having no assault history [30].

To summarize, the priorities of acute care counseling are to provide emotional support, assure a plan for patient safety, and assess coping skills and strength of support system post-discharge. When possible, arrangements should be made for ongoing counseling through sexual assault crisis programs. In anticipation of the long-term adverse effects of sexual assault, arrangements should be made for primary care follow-up and patients and families should be offered information and access to mental health services.

The American Academy of Family Practice has published guidance for clinicians caring for patients in the aftermath of sexual assault, emphasizing the need to be prepared for patient disclosures and ready to respond in an empowering and compassionate manner. Practical suggestions are provided for conducting the clinical encounter, including how to respond to the patient's disclosure and recommendations for managing the physical examination. This reference piece, entitled Communication Tips for Caring for Survivors of Sexual Assault, is available at https://www.aafp.org/pubs/fpm/issues/2019/0700/p19.html [40].