Sexual Assault – Basics, Clinical Manifestations, Diagnosis, Treatment
Sexual assault is defined as any sexual act performed by one person on another without that person’s consent. Components of this violent act include the use or threat of force and/or the inability of the victim to give appropriate consent.
APPROACH TO THE PATIENT
- The management of a sexual assault case should be done with compassion and professionalism.
- Informed consent must be obtained before the physical and forensic examination of an assault victim in the emergency room.
- The duties of the examining physician include the following:
- Treating injuries
- Performing appropriate tests to detect, prevent, and treat sexually transmitted infections
- Detecting pregnancy, and preventing or terminating it, according to the woman’s wishes
- An initial assessment for unstable vital signs, altered consciousness, peritoneal injury, and pain will alert physicians to severe lacerations, fractures, or internal injuries.
- After the assessment and treatment of acute injuries, a focused history should be taken and a physical examination performed. When the examining physician is a man, a female caregiver should be present.
- The site and time of the assault; the race, identity, and number of assailants; and the nature of the physical contacts, weapons, and restraints should be noted.
- Bathing, douching, wiping, dental hygiene, bowel movements, and changes of clothing should be documented.
- A history of previous gynecologic conditions should be recorded, including infections, contraceptive use, and dates of the last menstrual period and the last episode of consensual intercourse.
- The physician should identify all injuries.
- Photographs of major injuries should be taken if feasible. Careful pelvic examination (with colposcopy if indicated) should be performed. It is important to use only saline for lubrication (for appropriate collection of forensic specimens).
- A rectal examination should be considered if anal penetration occurred or if signs of trauma are identified.
- Standard rape kits are available in most emergency departments and contain the necessary equipment for the collection of forensic specimens from the rape victim.
- Spousal rape is often more violent, and it is less commonly reported.
- Two-thirds of the sexual assaults in an urban locale are committed by people known to the victims, and over two-thirds of these assaults are associated with physical trauma.
- Sexual assault is one of the most increasingly occurring violent crimes in the United States. In 1990, the Department of Justice reported that the annual incidence of sexual assault was 80 per 100,000 women, accounting for 7% of all violent crimes. Although the incidence of rape peaks among girls and women 16 to 19 years old in the United States, more than 60,000 rapes of women older than 50 years of age are reported annually.
- The frequency of date rape is reportedly as high as 20% among adolescent girls, peaking in the 16- to 19-year-old age group.
- Up to 5% of rape victims have major nongenital physical injuries.
- Approximately 1% of victims have moderate or severe genital injury requiring surgical intervention.
- In 0.1% of assaulted women, the injuries sustained are fatal.
- The incidence of sexual assaults against men has not been studied extensively. Of a sample of 1,480 men in Los Angeles, 7% reported being “pressured or forced to have sexual contact” after the age of 16. In a cross-sectional survey conducted in the United Kingdom among 2,474 men, 3% reported nonconsensual sexual experiences as adults.
- Over 5% of men report sexual abuse as children; nonconsensual sexual experiences as a child are predictive of nonconsensual sexual experiences as an adult.
- A victim of sexual assault suffers psychological injury in addition to physical harm.
- Usual injuries are upper vaginal lacerations that present with profuse vaginal bleeding and pain.
- Genital trauma is common, even in rape victims who are asymptomatic.
- Bite marks on the genitalia and breasts are common. The oral cavity should be carefully inspected to identify trauma.
- The assault is often followed by a “rape trauma syndrome.” The short-term phase may last for hours or days and consists of the emotional shock, disbelief, and despair caused by a life-threatening event. The long-term phase of the syndrome, during which the victim attempts to restructure her life and relationships, may last months or years.
- Baseline serologic tests for syphilis and hepatitis B, ABO blood typing, and measurement of serum human chorionic gonadotropin (for women of reproductive age) should be performed after the physical examination. Other tests include the following:
- HIV testing (repeat at 6 weeks, 3 months and 6 months)
- Gonorrhea, chlamydia, and syphilis tests
- Wet mount for Trichomonas
- Pregnancy test (if indicated)
- Hepatic enzyme tests (repeat as indicated)
- Complete blood count (repeat as indicated)
- Swabs for gonorrhea and chlamydia cultures should be obtained from the cervix and from the rectum (if there was rectal penetration).
- Studies have demonstrated HIV antibodies in vaginal washings following unprotected intercourse with an HIV-infected male partner who has ejaculated. However, the frequency of false-negative results with vaginal washings, together with the low prevalence of HIV infection in perpetrators of sexual assaults, makes the predictive value of HIV testing of vaginal washings too low to be useful as a screening tool.
In most patients, only limited injury to the rectum is evident on proctoscopy; spontaneous hemostasis is common, requiring no intervention. However, one-third sustain deep lacerations that require transanal suture repair, hospital admission, and treatment with broad-spectrum antibiotics.
- Rape may increase the risk of HIV transmission compared with consensual sex, because trauma is more likely.
- Intraperitoneal extension of a vaginal laceration is rare but, when present, requires exploratory laparotomy and broad-spectrum antibiotic therapy.
- The most common infections acquired from assault are Trichomonas infection, bacterial vaginosis, and Chlamydiainfection. The Centers for Disease Control and Prevention estimate that the risk of an adult rape victim’s acquiring gonorrhea as a result of sexual assault is 6% to 12%. The risk of Chlamydia infection is 4% to 17%, and the risk of syphilis 0.53%. Although seroconversion for HIV antibody has been reported among persons whose only known risk factor was sexual assault, the risk of acquiring this infection is less than 1%.
- A follow-up plan should be established for both medical and psychological evaluation.
- In general, the patient should be seen for medical follow-up after 2 to 4 weeks. If the patient did not receive antibiotic prophylaxis, cultures for gonorrhea and chlamydia and examination of slides of vaginal secretions for trichomonas and bacterial vaginosis should be repeated at 2 weeks. Repeated serologic tests for syphilis at 4 to 6 weeks are recommended. An initial vaccination against hepatitis B should be done, and repeat doses scheduled 1 and 6 months later.
- A study reviewed the follow-up appointments from adolescent and adult victims. Only 31% of all sexual assault victims returned for a follow-up visit. Physical complaints were reported by 42.6%, but 98.0% had normal findings at a general examination, and 94.8% had a normal result of gynecologic examination. Since the assault, 49.2% had been sexually active, 10.0% with multiple partners and 73.3% without consistent condom use. Disturbances in sleep, sexual function, and appetite and assault-related fears were commonly reported among victims.
- Prophylactic antibiotic therapy for sexually transmitted diseases should be prescribed if the assailant is known to be infected, if the victim has signs or symptoms of infection, or if prophylaxis is requested. If the patient is known to have been pregnant at the time of the assault, erythromycin or azithromycin may be substituted for doxycycline, and metronidazole should be administered only after the first trimester.
- Tetanus prophylaxis is appropriate for unimmunized patients with trauma.
- If the patient is found to be at risk for pregnancy as the result of assault, “morning-after” prophylaxis should be offered.
- Clinicians caring for rape survivors may recommend postexposure prophylaxis. When the choice is made to take medications to prevent HIV infection, treatment should be initiated as soon as possible. Usual prophylactic regimens for postexposure prophylaxis for HIV include the following:
- Zidovudine 300 mg PO bid or 200 mg PO tid and lamivudine 150 mg PO bid for 28 days
- Didanosine 200 mg PO bid and stavudine 40 mg PO bid (consider adding nelfinavir 750 mg PO tid or indinavir 800 mg PO tid) for 28 days
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