Evaluation and management of adult and adolescent sexual assault victims

INTRODUCTION — Sexual assault is defined as any sexual act performed by one person on another without consent. It may result from the use of force, the threat of force, or from the victim's inability or refusal to give consent. Sexual assault victims do not "entice" their assailants; sexual assault is an act of conquest and control.

The evaluation and treatment of adult and older adolescent victims of sexual assault are discussed here. Caring for child victims of sexual assault, general trauma evaluation and management, and sexually transmitted infections are all reviewed separately. (See "Management and sequelae of sexual abuse in children and adolescents" and "Evaluation of sexual abuse in children and adolescents" and "Initial management of trauma in adults" and "Screening for sexually transmitted infections".)

EPIDEMIOLOGY — According to an extensive systematic review of studies of sexual violence perpetrated by non-partners, sexual violence against women is common throughout the world [1]. The review noted that data is scant in particular regions (central sub-Saharan Africa, Middle East, Eastern Europe, Asia Pacific) and therefore, must be interpreted cautiously, but reported that the prevalence appeared to be highest in central sub-Saharan Africa (21 percent; 95% CI 4.5-37.5) and southern sub-Saharan Africa (17.4 percent; 95% CI 11.4-23.3). When interpreting this study, it is important to remember that sexual violence perpetrated by intimate partners was not included, and that were such data added the overall prevalence would be much greater.

The lifetime prevalence of sexual assault in the United States is approximately 18 to 19 percent in women and 2 to 3 percent in men [2,3]. In a national phone survey of college women, 2.8 percent reported a completed or attempted sexual assault in a given year; the estimated cumulative rate over four years may be as high as one in four [4].

Many cases of sexual assault involve alcohol or drugs [5-7]. In one series, almost 30 percent of undergraduate women reported a drug-related assault, with alcohol the most common substance involved [5]. A study of Canadian women college students reported that nearly 80 percent of sexual assaults involved alcohol or drugs [6]. There may be some educational programs that can reduce the risk of sexual assault on college campuses [8,9]. A majority of sexual assault victims have some acquaintance with their attackers [10]. Two-thirds of assaulted women over 55 are assaulted in their own home or in a care facility [11]. In men, the prevalence of assault appears to be higher among those who are gay, bisexual, veterans, prison inmates, and those seeking mental health services [12].

Historically, statistics from the United States federal government included only assaults upon women in the category of "forcible rape." In 2013, the definition was changed to "penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim" and has been broadened to include male victims, though this still excludes statutory rape. Annual statistics about sexual assault in the United States are available from the Department of Justice [13]. However, reported sexual assaults probably represent only a fraction of those committed. Only 10 to 15 percent of all sexual assaults are reported to police, and women who know their assailant are less likely to report the assault [14].

SCREENING — The issue of screening for domestic violence, including sexual assault, is reviewed separately. (See "Intimate partner violence: Diagnosis and screening".)

EVALUATION

Overview — The assessment of sexual assault victims includes several domains [15-18]:

●Assessment and treatment of physical injury with special focus on the genitalia

●Psychological assessment and support

●Pregnancy assessment and prevention

●Evaluation, treatment, and prevention of sexually transmitted infection

●Forensic evaluation

When possible, acute evaluation should be done by providers specifically trained to care for victims of sexual assault. Others may do the evaluation in one of the following circumstances:

●A trained provider is not available.

●The patient prefers that the examination be done by another provider and cannot be dissuaded, understanding that flawed evaluation may affect the likelihood of identification and prosecution of the perpetrator. Bias may be presumed if the provider is a friend or personal physician to the victim.

●The evaluation is occurring later than the locally determined interval for formal evidence collection, which varies from three to seven days.

Complete evaluations are time intensive and may require three to six hours. Proper evaluation requires maintenance of the chain of custody of evidentiary material. Providers may be asked to testify in court if cases are prosecuted. Patients must be counseled about each component of the evaluation and documentation. They may choose to decline some portions after education on the rationale for the procedure and the impact of their choices on health and prosecution outcomes.

Requirements for the forensic evaluation will vary by jurisdiction, and it is important for the provider performing the evaluation to know local requirements.

Trained providers — Many institutions in the United States have established SANE (Sexual Assault Nurse Evaluation) models or related programs for acute care [18-20]. Similar programs exist in Canada and England [21,22]. The Association of International Forensic Nurses is a source of information on programs in other countries [23]. Some programs train a broader range of clinicians including physicians, physician assistants, and advanced practice nurses who might then be referred to as sexual assault forensic evaluators (SAFE clinicians). The United States Department of Justice has established standards for such training [24].  

These trained providers can:

●Expedite evaluation

●Improve the consistency and quality of collected forensic evidence and ensure adherence to specific protocols regarding evidence collection and maintenance of the legal "chain of evidence" (see the National Institute of Justice website)

●Coordinate state crime lab testing, if appropriate, including assessment for "date rape" drugs (Rohypnol, and gamma hydroxybutyrate [GHB]) when appropriate

●Increase success of criminal prosecution and provide a bridge between the medical and criminal justice systems

●Link the victim with community services including Rape Crisis Centers

●Improve sensitivity to the psychological trauma experienced by sexual assault victims

SANE programs are supported at the federal level in the United States by the Department of Justice, Office of Victims of Crime. State specific information is available at centers.rainn.org.

History — The history should focus upon precise details of the sexual assault for forensic purposes in the event of sexual assault prosecution. Details will also guide the trauma assessment and will help to assess the risk of pregnancy and sexually transmitted infection.

Histories must be obtained in a sensitive and supportive manner. Advocates can support patients and help them articulate their needs and questions during the history, but advocates should not respond to questions and care should be taken to avoid asking questions in a leading or suggestive manner. Family members or other patient supports should be counseled that they might be subpoenaed as witnesses if present and that they should remain passive and silent for the evaluation [20].

The following details of the history should be obtained:

●Circumstances of the assault, including date, time, location, use of weapons, force, restraints, or threats.

●Whether or not the victim experienced loss of consciousness or memory loss.

●The assailant's physical description along with the assailant's use of drugs or alcohol.

●Specifics regarding oral, vaginal, or anorectal contact or penetration along with presence or absence of ejaculation and/or condom use.

●Areas of trauma should be ascertained focusing especially upon the victim's mouth, breasts, vagina, and rectum.

●Bleeding on the part of either assailant or victim may be relevant in assessing the risk of hepatitis or HIV transmission. The source of genital bleeding must be ascertained as it can be life threatening.

●Recent consensual sexual activity before or after the assault including details about site of contact (oral, genital, anorectal) and condom use.

Victims should be asked if they have wiped, showered or bathed, changed clothing, eaten, used toothpaste or mouthwash, used enemas, changed or removed a tampon, sanitary pad, or barrier contraceptive device since the assault. Such activities can lower the yield of forensic specimen collection.

Physical examination — Note that some states require specific forms for documenting the history and examination.

The patient should undress for the examination with a sheet beneath them to capture any falling debris for medical evidence. The physical examination should describe the patient's emotional state. The examiner should document any evidence of trauma. If possible, photographs of injuries should be taken, with the patient's consent. A ruler or an easily identified object is helpful for indicating the size of objects in photographs. Physical examination evidence of trauma is more likely to be present with examination within 72 hours of assault, and when assaults occurred out of doors or were perpetrated by strangers [25].

Extragenital trauma may be more common than anogenital trauma (70.4 versus 26.8 percent) with bruises, abrasions, or erythema on the thigh, upper arm, face or neck particularly common [26]. In women, the breasts, external genitalia, vagina, anus, and rectum should be carefully examined. Common sites of genital injury include the posterior fourchette and the labia minora. As compared to women who have had consensual sex, assaulted women are more likely to have genital lesions at sites other than the posterior fourchette, and are more likely to have multiple areas of trauma [27]. Genital trauma occurs more commonly in postmenopausal women and adolescents [14,28], and detectable trauma is more likely in women reporting vaginal or anal penetration and in virgins [29]. Suggested terminology for describing examination findings includes the TEARS categorization: Tears (defined as any break in tissue including fissures and lacerations), Ecchymoses, Abrasions, Redness, and Swelling [30].

Colposcopic examination can enhance detection of areas of milder genital trauma and is now performed by most SANE programs [31,32]. A Wood's lamp or other UV light source may help identify foreign debris and semen on the skin. Evidence of anogenital trauma is enhanced with colposcopy or use of toluidine blue dye (TBD). However, toluidine dye can be difficult to use and is not endorsed in all United States jurisdictions.

In male victims, close attention should be paid to the thighs, penis, glans, urethral meatus, scrotum, and perineum, evaluating for erythema, scars, ecchymosis, excoriation, or laceration [33]. Penile examination should focus particularly on the glans and frenulum, and should also assess for urethral discharge. Rectal examination should be considered and performed if there was anal penetration. Anal injury was documented in 14 percent of those consenting to examination in an Australian center [34].

Forensic evaluation — Forensic evaluation should be offered to victims of abuse, but is not mandatory and requires informed consent. If sexual assault is suspected but the patient is unable to provide consent, it is controversial as to whether or not to perform this examination. A previously identified guardian would be authorized to provide consent. In the absence of a guardian or surrogate decision maker, portions of the examination might be done if routine examination already requires examination of those areas, would not induce additional discomfort, and/or if a medical procedure is to be done that would destroy evidence [35].

Components of examination should not be done if they would require sedation, and photographs of intimate areas should not be taken without consent. Materials obtained prior to consent would only be released to law enforcement when consent is obtained later.

Forensic evaluation requires collection of numerous specimens. If the patient is brought by ambulance from the site of the assault, any sheets used to transport the patient and any debris on them should be kept [15]. Providers should use evidence collection kits with careful attention to guidelines for specimen collection. There are a variety of commercial collection kits available; some states require specific kits. Kits can be obtained through state distribution programs or directly from kit manufacturers. States in the United States are required to offer free evidence collection, irrespective of a victim's intent to pursue police reporting, in order to qualify for federal funds in the STOP program.

Collected samples include:

●The victim's clothing

●Swabs and smears from the buccal mucosa, vagina, and rectum and from other areas highlighted by ultraviolet light

●Combed specimens from the scalp and pubic hair

●Fingernail scrapings and clippings

●Control samples of the victim's scalp and pubic hair (ideally, at least 20 to 25 pulled hairs per site)

●Whole blood sample

●Saliva sample

Given the painful and invasive nature of plucking hairs and the fact that hair can be removed from a victim at a later date as long as the victim is available, some jurisdictions no longer require hair samples. It is best to check with the local prosecutor's office to clarify their policy. Kits contain specific collection materials, specific containers for each specimen obtained, and detailed collection instructions. Specimens may need to be dried; some jurisdictions mandate specific drying techniques. When completed, kits must be sealed, labeled, and stored using kit-specific directions to ensure rigor in maintaining an unbroken chain of evidence.

Samples are examined for spermatozoa and for acid phosphatase as an assay for semen; it is recommended that these analyses be performed in forensic laboratories [36]. Collected samples can also be analyzed for DNA. Sperm has been detected in vaginal samples up to 72 hours after assault and in anal samples up to 24 hours after assault; sperm are not generally detectable in oral samples [26].

The yield of evidentiary examinations generally declines with time and with specific behaviors, like changing clothes, showering, and brushing teeth. However, there is no absolute interval during which evidence must be obtained, and as DNA technologies develop the time available for evidence collection may expand [20]. As an example, swabs from external skin would not be useful in a victim who presents over 24 hours after an assault and has showered in the interim, but cervical and vaginal swabs, and possibly fingernail scrapings, would still be valuable. The key principle is that there is only one opportunity to collect evidence so when in doubt it is best to obtain it. Individual jurisdictions determine the maximal time interval during which certain evidence may be collected; intervals vary depending upon patient history, hygiene, and the specimen being obtained. Historically, many jurisdictions limited evidence collection to the first 72 hours after assault, but many jurisdictions have extended the period to five to seven days.

Perpetrator evaluation — Clinicians may occasionally be called upon to perform forensic evaluation of an assault perpetrator [37]. Principles for evidentiary examinations are similar to those for victims, and require evidence collection kits and strict attention to maintain the chain of evidence. Because the suspect has the right to remain silent, no history may be given but if the examiner inquires and the suspect responds then all historical information should be recorded. Swabs, hair combing, and fingernail sampling are obtained. Penile swabs should be collected from the shaft, glans, and area under the foreskin; finger swabs would be done in cases of digital penetration of a victim [38]. Bruises, scratches and bite marks are identified, with swabbing of bites and scratches to identify victim DNA. Blood samples for HIV and hepatitis B can be drawn and held; in many jurisdictions victims can ask the court to have the suspect tested.

Physical examination evidence of trauma is most common on the hands, forearms, face, and neck [26]. Permanent physical attributes, such as tattoos, are described. If victim and assailant are in the same facility, they should be evaluated in physically separate settings by different personnel to avoid any accusation of cross contamination of specimens.

Laboratory testing and diagnostic imaging — Laboratory evaluation is focused on trauma assessment, testing for sexually transmitted infections, and pregnancy testing. Radiographic imaging is guided by the history and physical examination. (See "Initial management of trauma in adults", section on 'Diagnostic studies'.)

Testing for sexually transmitted infection has been considered elective, as guidelines suggest empiric treatment of possibly acquired infections regardless and testing does not provide clear evidence of infection acquired at the time of assault (identified infections may be preexisting). Historically, there has been concern that positive tests might be used by the defense as evidence of promiscuity to discredit the victim, although many states limit the evidentiary use of a victim's prior sexual history [39]. However, although this rarely occurs, evidence of a sexually transmitted infection obtained at the time of the evaluation for assault could be accessed later, and some patients or providers may choose to defer testing for this reason.

Victims may forego testing if they plan to take prophylactic treatment for infections. Testing is particularly important for the patient who initially declines treatment to ensure that appropriate therapy can be provided.

Guidelines from the United States Centers for Disease Control and Prevention (CDC) suggest nucleic acid amplification testing (NAAT) in patients for chlamydia and gonorrhea at the site(s) of exposure (vaginal, anal, and/or oral), and vaginal trichomonas NAAT testing [39,40]. We agree with this approach. The World Health Organization recommends empiric treatment for sexually transmitted infections, but makes no recommendations regarding testing for infections during the evaluation [41].

Serum testing for HIV, hepatitis B, and syphilis are recommended. Although there are reports of sexual transmission of hepatitis C, there are no known reports of transmission associated with sexual assault and testing for hepatitis C is not addressed in current CDC recommendations. Given the relatively low risk, and the absence of protocols for prophylaxis against hepatitis C, most programs have not incorporated hepatitis C testing into the evaluation of sexual assault and we believe this is reasonable. (See "Screening and diagnostic testing for HIV infection" and "Hepatitis B virus: Screening and diagnosis" and "Syphilis: Screening and diagnostic testing".)

Wet preps may show motile sperm; jurisdictions vary as to whether the examiner or the forensic laboratory is to make that evaluation. (See "Screening for sexually transmitted infections", section on 'Chlamydia and gonorrhea' and "Vaginal discharge (vaginitis): Initial evaluation" and "Treatment of uncomplicated Neisseria gonorrhoeae infections".)

Pregnancy testing should be performed for women of childbearing age. (See "Clinical manifestations and diagnosis of early pregnancy", section on 'Diagnosis'.)

Drug screening for flunitrazepam (ie, Rohypnol, the "date rape drug"), gamma hydroxybutyrate (GHB), and other drugs should be done selectively. Testing may be warranted if the victim has amnesia for any time surrounding the event, manifests suggestive signs or symptoms, or suspects that they were drugged. Alcohol may be the most common date rape drug; benzodiazepines and other sedatives may also be implicated [26]. Blood and urine samples are generally required; timing of collection of urine samples may be critical for maximal detection. Analysis of specific segments of hair can also be analyzed for drugs and correlated with timing of a past assault [42,43]. Samples should be analyzed by forensic laboratories rather than the laboratory of the examining facility. (See "Testing for drugs of abuse (DOAs)" and "Benzodiazepine poisoning and withdrawal" and "Gamma hydroxybutyrate (GHB) intoxication".)

It remains important to maintain a chain of custody though these samples are separate from the evidence collection kit. Patients should understand that drug testing may also reveal voluntary drug or alcohol use that potentially can be used by defense to discredit victims [20].

TREATMENT

Initial therapy — Fractures, soft tissue injuries, and other traumatic injuries should be treated appropriately. In one series, hospital admission was required more often in older than younger women, with 15.7 percent of women over 55 hospitalized [14]. (See "Initial management of trauma in adults".)

After urgent attention to trauma, the remainder of the initial treatment regimen should focus upon sexually transmitted infections (including hepatitis B and HIV), pregnancy, and psychosocial issues [15-17]. (See 'Psychosocial issues' below.)

Sexually transmitted infections — The United States Centers for Disease Control and Prevention (CDC) and others recommend empiric antibiotic treatment since many assault victims will not return for a follow-up visit, and treatment based upon testing results is therefore problematic [39,44]. In addition, patients often prefer immediate treatment. Empiric therapy includes ceftriaxone 500 mg by intramuscular injection (IM) plus azithromycin 1 g by mouth (PO) (single dose) to treat both gonorrhea and chlamydia. Metronidazole or tinidazole 2 g PO (single dose) is also recommended to treat trichomoniasis [39]. (See "Treatment of uncomplicated Neisseria gonorrhoeae infections" and "Treatment of Chlamydia trachomatis infection", section on 'Antibiotic treatment of chlamydia'.)

Patients who decline empiric treatment should be seen one week after the initial evaluation to determine the need for treatment based on initial testing, and for repeat testing if needed. (See "Screening for sexually transmitted infections".)

Prophylaxis against herpes simplex infection is not recommended as there is no evidence of its efficacy.

The risk of acquiring a sexually transmitted infection is difficult to measure due to the poor follow-up in many studies, and an infection transmitted during an assault may be present during the baseline examination since the initial evaluation can occur days after the event. One observational study performed in France of 326 adult and adolescent sexual assault victims reported that 15 percent of patients presenting for evaluation had chlamydia and 5 percent gonorrhea as detected by PCR, but this study did not provide information about the duration of time between the assault and medical evaluation [45]. Another study performed in Norway found that 6.4 percent of patients were positive for chlamydia at the time of assault [46].

Hepatitis B infection — The need for prophylactic treatment against hepatitis B virus (HBV) infection depends upon the patient’s history of vaccination, immune status, and exposure [39,40]. Persons with documented immunity against HBV or who have previously been infected with HBV are immune to reinfection and do not require post-exposure prophylaxis. Those who received hepatitis B vaccine as children likely would not have been tested for immunity; we suggest previously vaccinated patients not known to be immune receive a single hepatitis B booster vaccination. If the exposed patient is uncertain if they completed the hepatitis B vaccine, they should be treated as if they are unvaccinated. Follow-up doses of hepatitis B vaccine should be administered to complete the vaccine series. A table summarizing post-exposure prophylaxis against HBV is provided (table 1); prophylaxis is discussed in detail separately. (See "Management of nonoccupational exposures to HIV and hepatitis B and C in adults", section on 'Exposure to hepatitis B virus'.)

In addition to vaccination, treatment with hepatitis B immune globulin (HBIG) may be needed depending on circumstances. We suggest initiating vaccination and treating with HBIG if the HBV status of the assailant is positive or unknown and the patient meets either of the following conditions:

●Unknown vaccination history or no vaccination given against HBV

●Unknown history of infection or no history of infection with HBV

HIV infection — Prophylactic treatment with antiretroviral drugs for HIV following sexual assault should be addressed with every patient. Despite the presumed low risk of transmission and the lack of evidence proving the efficacy of antiretroviral drugs after sexual assault, many organizations and infectious disease specialists believe that they should be offered.

Antiretroviral drugs are best started within four hours of assault, and should not be prescribed if more than 72 hours has passed [47]. Options for prophylactic regimens used in postexposure prophylaxis (PEP) for healthcare workers are suitable for patients who choose to take HIV prophylactic treatment following sexual assault. These are described separately. (See "Management of nonoccupational exposures to HIV and hepatitis B and C in adults".)

We suggest consultation with a specialist familiar with PEP regimens. The CDC recommends that patients who decide to take PEP be given either an initial supply of PEP for three to seven days (starter pack) or the supply needed for an entire treatment course (28 days). In either case, short-term follow-up for further counseling is strongly recommended and would be required to complete treatment for those given only a starter pack [48]. Compliance with treatment may be low; a meta-analysis that included 26 studies involving more than 3000 victims of assault found that only 40 percent of patients completed prophylaxis [49].

There are no good data on the risk of acquiring HIV from an unknown assailant, although there are case reports of HIV transmission after sexual assault [47]. The risk of HIV transmission from a single episode of consensual vaginal intercourse with an HIV infected man is estimated at 0.1 percent, and from a single episode of consensual anal intercourse at 2 percent (see "Management of nonoccupational exposures to HIV and hepatitis B and C in adults"). The risk of transmission after sexual assault by an HIV infected man is likely to be higher, since there may be associated trauma and bleeding [50].

However, most assailants from countries with low population seroprevalence rates are unlikely to be infected with HIV. In a study of men incarcerated at a Rhode Island state prison from 1994 to 1999, of 1524 charged with a sexual offense only 1 percent were infected with HIV [51]. Other data, however, indicate that Rhode Island prison inmates overall had a low prevalence of HIV in 1994 compared with New York State inmates (3.8 versus 12.4 percent) [52]. HIV seroprevalence rates among prisoners have since declined nationally. The highest prevalence in 2008 was 5.9 percent in New York State, with many states reporting rates less than 1 percent [53].

While the overall risk of acquiring HIV after an assault by an unknown assailant is likely low, the risk may be increased by certain aspects of the assault:

●Male on male rapists might be expected to have a higher prevalence of HIV infection.

●Sexual assault in a region or country with a high background prevalence of HIV increases the likelihood that an assailant will be HIV infected. Country-specific data can be found at http://www.unaids.org/en/regionscountries/countries.

●Multiple assailants presumably increase the risk, since any of the assailants might be infected with HIV.

●Anal sexual assault may be more likely to transmit HIV.

●Sexual assault where either the assailant or the victim has trauma, bleeding, or genital lesions may increase the likelihood of transmission.

HPV infection — HPV vaccination is recommended in the CDC guidelines [39]. Vaccination is suggested at the time of initial evaluation after sexual assault in female survivors aged 9 to 26 and male survivors aged 9 to 21. There is no mention in the CDC recommendation of consideration of prior vaccination, but presumably this would not be done in those previously vaccinated. Follow-up vaccination to complete the series is recommended at 1 to 2 months and 6 months after initial vaccination. (See "Human papillomavirus vaccination".)

Pregnancy — Although the risk of pregnancy after a single episode of vaginal intercourse varies during the menstrual cycle, postcoital emergency contraception should be offered without regard to the menstrual cycle, given the uncertainty in the timing of ovulation.

In the United States, available approaches for oral emergency contraception include the progestin antagonist/agonist ulipristal, levonorgestrel alone, and the Yuzpe regimen. Ulipristal is effective up to 120 hours after intercourse and is the preferred drug treatment beyond 72 hours after unprotected intercourse and in overweight or obese women. Levonorgestrel (0.75 mg and repeated in 12 hours, or 1.5 mg as a single dose) is available over the counter in the United States and other countries. It is well-tolerated but less effective over time than ulipristal and is likely ineffective in women who are overweight. The Yuzpe regimen (100 mcg of ethinyl estradiol and 0.5 mg of levonorgestrel historically given as two oral contraceptive pills or its equivalent and repeated in 12 hours) is 75 to 80 percent effective if administered within 72 hours of intercourse, but is rarely used given its lower efficacy and the high incidence of nausea and vomiting [54]. Outside of the United States, mifepristone (600 mg single dose) is also available for emergency contraception [54]. (See "Emergency contraception".)

Insertion of a copper intrauterine device (IUD) is a highly effective method of emergency contraception, but there are no reports of programs that have integrated IUD placement into a sexual assault evaluation. In addition, this approach would add the complexity of a separate procedure that is not performed by emergency or SANE nursing staff. The copper IUD provides 10 years of highly effective contraception, but the implications that this should be considered by a woman who might be contemplating childbearing is likely inappropriate to raise in the setting of sexual assault.

Many patients will experience nausea and vomiting from the combination of antibiotics and contraceptives; HIV prophylaxis can also cause nausea and vomiting. Treatment with antiemetics is appropriate, and medications such as meclizine, ondansetron, or prochlorperazine are all reasonable choices. (See "Approach to the adult with nausea and vomiting", section on 'Drug therapy'.)

Psychosocial issues — Sexual assault victims require extensive emotional support and should be offered mental health services. Symptoms may include anger, fear, anxiety, physical pain, sleep disturbance, anorexia, shame, guilt, and intrusive thoughts.

Additionally, they may experience musculoskeletal, genital, pelvic, and/or abdominal pain. Anorexia and insomnia can persist. Dreams and nightmares are common, and phobias may develop. Victims may find it difficult to resume their habits, lifestyles, and sexual relationships [55]. Patients may develop posttraumatic stress disorder (PTSD), depression, or anxiety syndromes. (See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, assessment, and diagnosis" and "Unipolar depression in adults: Clinical features" and "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis".)

The risk of PTSD may be greater when assaults occur repeatedly during the event, are perpetrated by more than one assailant, or are associated with physical injury. Depression, acute stress disorder, and a history of more than two prior traumas also increase the risk of PTSD [56].

The medical evaluation and evidence collection process itself can be traumatizing and may compound the victim's sense of shame and loss of control. Providers should not force evaluation or treatment and should allow the victim some control in the evaluation process. A chaperone or advocate should be present during the evaluation.

Acute crisis counseling should include safety planning. Victims should be referred for ongoing counseling ideally through sexual assault crisis programs.

Documentation — Specific forensic forms should be included in evidence collection kits. These forms are used even if evaluation and treatment occur without evidence collection. Keeping the sexual assault report separate from the medical record is customary and has a precedent in psychiatric records. A face sheet documenting a "medical legal examination" is usually all that is needed in most states. Victims have serious concerns about access to the medical legal examination and photographs; appropriate advice should be given and consent obtained before the examination.

Legal issues — Legal definitions, procedures, and reporting requirements vary by country and, in the United States, by state. Some jurisdictions do not define sexual assault to include male victims and prosecution must occur under sodomy or other statutes. In most of the United States, only rapes involving children or elders require reporting by providers, while others require mandatory reporting for any sexual assault. Even when reporting is mandatory, victims can remain anonymous for examination and reporting purposes (eg, Jane Doe). Successful prosecution appears to be associated with evaluation within 24 hours of assault, performance of a physical examination, documentation of anogenital trauma and other injury, the use of a weapon, and assault in the context of an intimate relationship [57-59].

Evidence should be collected at the time of the initial evaluation and stored securely even if the patient is not planning to report the assault. Victims must sign consent forms prior to evidence collection. In addition, victims should be notified when the evidence is to be destroyed as mandated by United States law. In the United States, state-specific information on statistics and legislation regarding the backlog of untested kits can be found at http://www.endthebacklog.org/backlog/where-backlog-exists-and-whats-happening-end-it.

In the United States, many states have witness assistance programs to provide advice on reporting, navigating the legal system, and victim financial compensation. Conviction rates range from 8 to 20 percent in the United States [44]. Examiners should anticipate that they may be called to testify if a case is prosecuted.

Follow-up care — A follow-up medical visit should occur within one to two weeks of the acute evaluation. This provides an opportunity to review psychosocial supports for the victim and to offer counseling. If treatment for STDs was not initially provided, a medical visit at one week is necessary to ensure follow up of appropriate tests. At the follow-up visit, additional photographs of injuries can be taken to assess healing and document the time frame.

Compliance with follow-up medical care is often poor among victims of assault. Describing the short duration of the follow-up examination and the reasons for the visit at the initial evaluation and enlisting support from victim advocates are important ways to improve compliance. Ways to improve follow-up care may include permitting patients to return to the emergency department for follow-up if no other medical facility is available or making home visits through nursing or community medicine programs.

Pregnancy testing should be performed (even if the patient received postcoital contraception). Repeat testing for gonorrhea, chlamydia, trichomonas, and bacterial vaginosis should be done ideally one week after the assault in patients who declined prophylactic treatment. Testing is also indicated for those who develop interim symptoms, and in those who request testing.

The CDC recommends that rapid plasma reagin (RPR) be rechecked at four to six weeks and three months, and suggests that HIV postexposure testing should be offered at the same intervals [39]. Others suggest that serologic reexamination be done at 12 and 24 weeks only [19]. Patients should be counseled to abstain from intercourse until prophylactic treatment is completed and consider condom use until serologic testing is completed. Hepatitis B and HPV vaccination should be given at one month and six months to complete primary vaccination if indicated.

Long-term implications — Women with prior sexual assault are at increased risk for a number of psychological, physical, and behavioral adverse effects. These include:

●PTSD, anxiety, depression, and suicide attempt [60]

●Misuse of prescription sedatives, stimulants, steroids, and analgesics [61]

●For women with PTSD, anxiety related to pelvic examination and avoidance of cervical cancer screening [62]

●Irregular menses, pelvic pain, dyspareunia, and urinary infections [63,64]

●Decreased sexual satisfaction [65]

●Increased risk for cervical cancer [66]

PROVIDER PREPAREDNESS — A national protocol for sexual assault medical forensic evaluations of adults and adolescents is available on-line through the United States Department of Justice, Office of Violence Against Women [20].

Providers should learn about local resources for sexual assault victims before they are presented with a patient who has experienced assault. The following issues should be researched:

●Who are the available Sexual Assault Nurse Examiners (SANE) or other trained providers in the community? How can they be contacted?

●Are there cultural issues for members of the community which might require special adaptation for the evaluation of sexual assault? Are interpreters available?

●What are the local requirements for collection of evidence and for documentation? Evidence collection kits and forensic documentation forms should be available immediately when a patient presents needing evaluation.

●Is there a UV light source? Is a camera available? Is colposcopy available?

●What are the local requirements for toxicology screening for date rape drugs?

●What are the jurisdictional policies regarding mandatory reporting?

●What is the local contact for sexual assault crisis support services?

TREATMENT OF PERPETRATORS — The risk of repeat assault by sex offenders is decreased for those at increased age at the time of release from incarceration [67]. Studies of cognitive behavioral treatment to prevent recidivism in incarcerated sexual offenders report mixed results [68].

Several different medications have been administered to decrease recidivism, including selective serotonin reuptake inhibitors (SSRIs), cyproterone acetate, medroxyprogesterone acetate, and LHRH. LHRH may be the most effective treatment, although adverse effects include low bone density and gynecomastia [69].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: HIV screening and diagnostic testing" and "Society guideline links: HIV prevention" and "Society guideline links: Sexual assault".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Care after sexual assault (The Basics)")

●Beyond the Basics topic (See "Patient education: Care after sexual assault (Beyond the Basics)".)

SUMMARY AND RECOMMENDATIONS

●In the United States, one in three women will be a victim of sexual assault during her lifetime; 7 to 10 percent of sexual assault victims are male. Only 10 to 15 percent of sexual assaults are reported to the police. (See 'Introduction' above.)

●Evaluation of the sexual assault victim should be performed by a trained provider, if at all possible. A complete history should be documented. Evaluation should include psychological assessment, evaluation of areas of trauma, and examination of the breasts, pelvic and anorectal areas. Colposcopy should be performed, when possible, to detect genital trauma. (See 'History' above and 'Physical examination' above.)

●An evidence collection kit, with detailed instruction and containers for specimen collection, is necessary for a forensic evaluation. The victim should be evaluated as soon as possible after an assault, but evidence may be collected at later times depending upon factors such as patient history and hygiene. (See 'Forensic evaluation' above.)

●Screening for sexually transmitted infection is not necessary if prophylactic treatment is to be given. Laboratory testing should include pregnancy testing in women of childbearing age. Baseline serology for syphilis and hepatitis B may be useful and HIV counseling should be provided. Drug screening may be warranted if the victim was found unconscious or has amnesia for any time surrounding the event. (See 'Laboratory testing and diagnostic imaging' above.)

●We suggest giving empiric treatment for sexually transmitted infections, especially if the patient has declined testing for STDs (Grade 2C). Empiric therapy includes ceftriaxone 500 mg by intramuscular injection (IM) plus azithromycin 1 g by mouth (PO) (single dose), which treats both gonorrhea and chlamydia. Metronidazole or tinidazole 2 g PO (single dose) is also recommended to treat trichomoniasis. (See 'Sexually transmitted infections' above.)

●Hepatitis B vaccine should be given to patients who have not been previously immunized. HPV vaccine should be given in age-eligible patients who have not been previously immunized. (See 'Hepatitis B infection' above and 'HPV infection' above.)

●We suggest prophylactic treatment against HIV infection (Grade 2C). However, this issue is controversial. The risk of HIV transmission is low, and the efficacy of antiretroviral drugs is unknown. Nevertheless, most organizations do suggest treatment if it can be initiated within 72 hours of exposure, and ideally within four hours. We concur with this approach. (See 'HIV infection' above.)

●We recommend that postcoital contraception be offered to all patients. (See 'Pregnancy' above.)

●Acute crisis counseling should be offered. Many patients experience psychological and physical symptoms over many months following the assault. (See 'Psychosocial issues' above.)

●Patient follow-up should occur by two weeks, with psychosocial counseling, STD testing for patients who did not take empiric therapy or who have symptoms, and pregnancy testing. Hepatitis B and HPV vaccine should be given at one and six months to complete the vaccine course. HIV and RPR testing should be repeated at 12 and 24 weeks; some also recommend testing at six weeks. (See 'Follow-up care' above.)