128 Sexual Assault
Key Points• Sexual assault requires the emergency physician to competently and comprehensively evaluate and treat the physical, emotional, and legal needs of the patient.
• Management includes medical stabilization, treatment of physical injuries, emergency contraception, prophylaxis for sexually transmitted diseases, assessment of risk for nonoccupational postexposure prophylaxis, forensic evaluation and evidence collection, crisis intervention, arrangement for follow-up medical care, and referral to social support and legal services.
Epidemiology
Sexual assault is sexual contact of one person with another without appropriate legal consent. The precise definition varies slightly from state to state, and health care providers should familiarize themselves with the definition in their jurisdiction. It is a widespread occurrence that permeates every facet of our society and can affect anyone regardless of gender, age, race, or socioeconomic status. In 2009, 88,097 forcible rapes were reported to law enforcement in the United States.1 This number is estimated to represent only 40% of the total sexual assaults because the majority of cases go unreported.2 The National Violence Against Women Survey found that 18% of surveyed women (1 in 6) and 3% of surveyed men (1 in 33) had experienced an attempted or completed rape at some time in their lives.3 The majority of females are assaulted by acquaintances or intimate partners and 32% by a stranger. Young females between the ages of 16 and 24 are disproportionately affected.4 For affected males, underreporting of their victimization is the norm. During the last decade, an alarming increase has been observed in reports of drug-facilitated sexual assault (DFSA).5
Differential Diagnosis and Medical Decision Making
Multidisciplinary Approach
Emergency physicians (EPs) are responsible for managing both the medical and forensic needs of patients with a report of sexual assault. This is best accomplished in an organized manner, such as with a sexual assault response team (SART). Members include a sexual assault forensic examiner (SAFE), victim advocates, law enforcement officers, crime laboratory personnel, and prosecutors. A SAFE has specialized knowledge and training to perform the forensic evaluation with a standardized sexual assault evidence collection kit (SAECK). Research has shown that use of a SART/SAFE program improves the quality of forensic evidence with an increase in prosecution rates over time.6 In jurisdictions in which such teams are unavailable, ED providers are responsible for the forensic examination, and it is therefore prudent that EPs familiarize themselves with their state-specific SAECK.
Consent for Forensic Evaluation and Evidence Collection
Patients should be informed of all of the options available to them, including forensic evaluation and evidence collection, depending on timing of examination. Before proceeding with any part of this evaluation, written informed consent for all aspects of the evaluation must be obtained as listed in Box 128.1. The patient has the right to refuse all or some parts of a forensic examination, and consent can be withdrawn at any time during the examination.
History
For the ED medical record, the history of the assault should be focused on details that affect medical management of the patient in the ED, including information that will help determine the risk for injuries and what treatment of sexually transmitted diseases (STDs) should be offered. In contrast, the forensic record is driven by strict policies and procedures and should include only medical information that has a direct bearing on evaluation of the reported crime. Material that is generally considered to constitute useful background in a therapeutic context may have a prejudicial effect in a forensic context and should not be included in the forensic record. Examples include the number of previous pregnancies, past mental health treatment, and remote substance abuse. Documentation should be concise and directly relevant to the assault, including any information that is necessary to properly interpret the current physical findings. Many SAECKs contain preprinted forms that help the examiner with the history-taking process to facilitate proper documentation. Salient features of the history that should be obtained for documentation in the forensic medical record are listed in Box 128.2.7,8
Box 128.2 Pertinent Historical Features of a Sexual Assault for Forensic Documentation
Date, time, location, and physical surroundings of the assault
Date and time of hospital examination
Loss of memory or periods of unconsciousness
Patient’s narrative of events as they pertain to sexual acts or the trauma sustained
Total number of assailants and relationship to the patient
Weapons, restraints, or force used
Specific sexual acts, including:
Hygiene events after the assault
Physical Examination
Physical examination is necessary to evaluate for signs of any trauma sustained during the sexual assault. The reported incidence of nongenital physical injuries ranges from 23% to 85%.8–15 When injuries are sustained, those most commonly seen are soft tissue injuries involving the head, face, neck, and extremities. Blunt force trauma, including penetrative blunt mechanisms, may produce contusions, which are associated with swelling, pain, tenderness, and discoloration, and lacerations from tearing of the tissues. A friction mechanism may cause abrasions. Sharp-force trauma may produce incised wounds. Bites may involve multiple mechanisms of injury. Patterned injuries suggest the specific object, weapon, or mechanism used to produce its characteristic shape.
Published rates of female genitoanal injury vary widely from 6% to 65%, with most investigators reporting a range of 10% to 30%.8–18 Risk factors for injuries included examination within 24 hours of the assault, presence of nongenital injury, threats of violence, and age younger than 20 and older than 40 years.8–18 The genital structures most frequently injured as a result of a penetrative mechanism are the fossa navicularis and posterior fourchette, followed by the labia minora and hymen. It is paramount that these areas be inspected carefully during the examination.
Forensic Evaluation: Evidence Collection and Chain of Custody
Once a patient consents to evidence collection, the steps delineated in the kit should be followed. Evidence collection should be guided by the history of the assault. Box 128.3 lists potential specimens to be gathered for forensic evidence collection.19,20
