As many as 1 in 3 women and 1 in 6 men experience some form of sexual violence in their lifetime. Treating patients who present after sexual assault can be challenging. The patient may be ashamed and unwilling to give a clear history of the assault at precisely the time when such history is critical for timely treatment and forensic documentation. The need for both treatment and evidence collection means that clinicians may simultaneously find themselves advocates for the patient and assistants to state and local law enforcement. It is vital to both the health of the patient and the well-being of society that medical professionals know how best to proceed in such cases.
Do you know best practices and key aspects of guidelines related to patients who have experienced sexual assault? Here are 5 Tips to deal with Sexual Assault.
Document all potential identifying information about the alleged assailant,
No patient should feel interrogated, and the physician is not responsible for investigating all aspects of the sexual assault. However, according to the AAFP, the following is recommended if women who have been sexually assaulted offer information:
- Try to use the patient’s exact words.
- Use the phrase “sexual assault” and avoid using the term “rape,” which is a legal and not a medical term.
- Document any identifying information provided about the assailant as well as the patient. This includes the date, time, and location of the assault; any specific circumstances related to the assault, including details about the specific sexual contact and any bodily fluids involved; and any activities the patient has done since the assault (eg, bathing, changing clothes).
- Note any use of restraints (eg, weapons, drugs, alcohol).
- Review the patient’s gynecologic history, including the most recent consensual sexual encounter.
Most prepubertal girls who have experienced sexual abuse or assault have normal gynecologic examination findings
Most cases of suspected or substantiated sexual abuse of prepubertal girls have normal examination findings. This may be due to elasticity of the hymenal tissue and genital mucosa and rapid healing of any injuries. Findings of sexual abuse in boys may include injuries to the glans, shaft of the penis, or scrotum. Anal findings are unusual but may include scars (most apparent if located off the midline), distorted or irregular folds, flattening of the anal folds, and poor anal tone. Anal soiling, lacerations, and dilatation may also be present in children with history of anal penetration and sexual abuse.
The forensic interview differs from a good medical history. This interview is essential to prosecution of a case and is often a critical aspect of the evaluation. The forensic interview is mostly concerned with detailed answers to who, what, where, and when the abuse occurred. The forensic interview should not replace the medical history obtained by the healthcare provider.
Photography can be used, but only if the patient consents. Consent for photographs in children who have experienced sexual assault may not be necessary if the case is under investigation by Child Protective Services, but it is recommended. A body diagram is typically used as part of the medical record to document any physical injuries, including abrasions, lacerations, bite marks, scratches, and ecchymoses.
Nucleic acid amplification testing (NAAT) is preferred for the diagnostic evaluation of adolescent or adult sexual assault survivors
Decisions to perform baseline STD testing should be made on an individual basis. An initial examination might include the following procedures:
- NAAT for Chlamydia trachomatis and Neisseria gonorrhoeae is preferred for the diagnostic evaluation of adolescent or adult sexual assault survivors.
- NAAT from a urine or vaginal specimen or point-of-care testing (ie, DNA probes) from a vaginal specimen for Trichomonas vaginalis may be indicated. Point-of-care testing and/or wet mount with measurement of vaginal pH and KOH application for the whiff test from vaginal secretions should be performed to identify evidence of bacterial vaginosis and candidiasis, especially if vaginal discharge, malodor, or itching is present.
- A serum sample for evaluation of HIV, hepatitis B, and syphilis infections may also be performed.
All patients should be offered antibiotic prophylaxis, regardless of results from preliminary STD screening. Cultures of exposed body sites (eg, oral, throat, vaginal, rectal) are recommended as appropriate. According to the CDC, US Food and Drug Administration (FDA)–approved NAATs are an acceptable substitute for culture, as long as positive test results are confirmed by a second study. Other tests (eg, EIA, nonamplified probes, direct fluorescent antibody tests) are not considered acceptable alternatives by the CDC because of unacceptable false-negative and false-positive result rates.
Anoscopy may be performed in male victims, and it may be combined with colposcopy in female victims
Colposcopy, where available, may have considerable value in documentation because it allows photographic recording of injuries. Anoscopy may be performed in male victims, and it may be combined with colposcopy in female victims. Evidence suggests that if speculum examination is performed before toluidine blue application to the posterior fourchette (to enhance small lesions that may occur during forceful genital penetration), the speculum itself may cause small lesions that will take up the dye. These iatrogenic lesions will be seen on colposcopy. Clinicians should consider deferring speculum examination until after external colposcopy if toluidine blue is to be used.
Imaging studies are only indicated for evaluation of comorbid trauma. To collect evidence, most hospitals have a prepackaged rape kit with the necessary equipment and detailed instructions. However, if the sexual assault victim presents 72 hours after the event (96 hours if the victim is a child), the evidence collection kit is no longer needed for legal documentation of the case, although some authors have reported finding evidence in children beyond this time frame.
Human papillomavirus (HPV) vaccination is recommended for female survivors aged 9-26 years and male survivors aged 9-21 years
According to the CDC, HPV vaccination is recommended for girls and women aged 9-26 years and boys and men aged 9-21 years. Men who have sex with men and have not received the HPV vaccine or who have been incompletely vaccinated can receive vaccination through age 26 years. The vaccine should be administered at the time of the initial examination, with follow-up doses administered at 1-2 months and 6 months after the first dose.
An empiric antimicrobial regimen for chlamydia, gonorrhea, and trichomonas is recommended by the CDC. The CDC also recommends postexposure hepatitis B vaccination (without HBIG) if the hepatitis status of the assailant is unknown and the survivor has not been vaccinated previously. If the assailant is known to be HBsAg positive, unvaccinated survivors should receive both hepatitis B vaccine and HBIG. The vaccine and HBIG should be administered to sexual assault survivors at the time of the initial examination, if indicated, and follow-up doses of vaccine should be administered 1-2 and 4-6 months after the first dose. Survivors who were vaccinated previously but did not receive postvaccination testing should receive a single vaccine booster dose.
HIV PEP is individualized according to risk and must be started as soon as possible, and within 72 hours of exposure for HIV-uninfected persons. A 28-day course of PEP is recommended, as follows: Tenofovir disoproxil fumarate (TDF) 300 mg orally (PO) daily and emtricitabine 200 mg PO daily plus raltegravir 400 mg PO twice daily or dolutegravir 50 mg PO daily.
Patients should be referred to a sexual assault center for aftercare and community resources. Given the long-term emotional and psychosocial impact of sexual assault on the victim, aftercare is vital.
About the Author
Richard H. Sinert, DO, is a Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Vice-Chair in Charge of Research, Department of Emergency Medicine, Kings County Hospital Center, Brooklyn, New York