Managing Sexual Assault in the Emergency Department
Author: Erica Simon, DO, MHA (@E_M_Simon, EM Chief Resident at SAUSHEC, USAF) and Daniel Sessions, MD (Medical Toxicologist, South Texas Poison Center / Assistant Program Director at SAUSHEC, USA) // Edited by: Courtney Cassella, MD (@Corablacas, EM Resident Physician, Icahn SoM at Mount Sinai) and Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)
It’s seven o’clock on a Saturday morning; as you sip your coffee in a feeble attempt to awaken neurons, you glance up as a nurse passes, leading a young female to a room. The woman appears distraught and disheveled: dress wrinkled, eyes bloodshot, cheeks tear-stained and blackened by the previous night’s makeup. As you glance at the patient tracking board, you note her chief complaint: Alleged Sexual Assault. Engrossed by a sickening, sinking feeling, you attempt to locate your department’s sexual assault protocol binder. As you walk toward the room you prepare yourself mentally for what will likely be an emotionally taxing encounter for all involved.
If you’ve found yourself in a situation similar to that depicted above, and could use a refresher on this important topic: read on as we discuss must knows for the ED management of sexual assault.
Epidemiology of Sexual Assault
Between 300,000-700,000 American women are sexually assaulted annually.1 While 94% of assault patients who present to emergency departments are females, current studies indicate a lifetime prevalence of sexual assault as occurring among 1 in 33 males.2 Adolescents disproportionately represent the majority of sexual assault victims (incidence peaking between the ages of 16 –19 years), with approximately 40% of this population reporting assault during their first sexual encounter.3-5
Contrary to popular belief, nearly 80% of persons having experienced sexual assault report knowing their offender; 18% identifying their assailants as former spouses or love interests.6 Hailed as one of the most widespread and under-reported violent crimes in the U.S.7, rape is associated with non-genital trauma in 40-81% of cases, with 5% requiring hospitalization for serious injury.5,8,9
The Role of the Emergency Physician
This review will address patient stabilization, provide recommendations for obtaining a medical and assault history, and detail pregnancy and sexually transmitted infection prophylaxis. An in-depth discussion of the forensic examination will be omitted, as requirements regarding healthcare provider training, tools contained within forensic collection kits, time allotted between alleged assault and court admissible evidence collection, and chain of custody legislation vary according to individual state law.
Stabilizing the Patient
The evaluation of an emergency department patient begins with an assessment of the ABCs. In extreme cases, patients with non-genital trauma may present with internal injuries, blunt head injury, and knife or gunshot wounds (2%)10 requiring intervention to address altered mental status or hemodynamic instability. After life- or limb-threatening injuries have been addressed, the patient should be moved to a quiet setting to begin discussion of consent and history taking.5,7
Providing Information & Obtaining Consents
Aside from immediate stabilization, information is the most valuable tool in caring for your patient.
Understand the limitations of the evaluation and treatment which your organization is capable of providing (to include the forensic examination), be familiar with state laws regarding timelines for reporting, and arm yourself with resources for referral (forensic exam specialists, counselors, chaplains, etc.) as appropriate.
If needed, state attorney’s offices may be contacted regarding the provision of a patient advocate. In addressing the patient, it is important to inform him/her that he/she may undergo forensic examination without the requirement for reporting.10 The typical time frame for evidence collection is within 72 hours to 5 days. Providers should check within their state what is the maximum time frame post assault for court admissible evidence collection. It is highly recommended that an advocate be provided to assist the patient during the examination, and facilitate the sharing of information regarding legal options.10,11
Consents must be obtained for information gathering and performance of a forensic examination.5,11 If the patient would like to report the assault, local law enforcement personnel must be contacted. The patient should be advised of state legislations/circumstances, which require mandatory reporting. Examples include12:
- Sexual assault of an elderly person or vulnerable adult
- Sexual assault of a minor (categorization as a “minor” varies from state to state)
- Non-accidental trauma
- Injuries sustained secondary to criminal conduct (definitions of “criminal conduct” vary by state)
- Assault with a deadly weapon
Obtaining an Appropriate Medical & Sexual History
In an effort to avoid repeated psychological trauma, portions of the medical and sexual history may be deferred until a later time at which an interview and forensic examination is to be conducted by the state certified/trained personnel. Medical history taking should include a query of the following:
|Last Menstrual Period|
|Recent (60 days) anal-genital injuries, surgeries, diagnostic procedures or medical treatments that may affect the interpretation of current physical findings|
|Pertinent medical condition(s) that may affect the interpretation of physical findings (blood dyscrasias, etc.)|
|Pre-existing physical injuries prior to the alleged assault|
|Pre/Post Assault History5,11|
|Other intercourse within the previous 5 days (anal, vaginal, or oral); intercourse with or without ejaculation; condom use|
|Voluntary alcohol or drug use prior to the assault|
|Voluntary alcohol or drug use between the time of the assault and presentation for examination|
|Post Assault Hygiene History (Presenting ≤ 72 hours Post Assault)5,11|
|Bodily functions: urination, defecation|
|Utilization of genital or body wipes or douches|
|Removal or insertion of tampons or diaphragms|
|General hygiene activities: bathed/showered/washed; changed clothing; ate or drank; brushed teeth or gargled|
|Assault Related History5,11|
|Loss of memory/consciousness|
|Presence of non-genital or anal-genital injury|
|Date/Time/Location of assault|
|Alleged assailant(s)/Age/Gender/Ethnicity/Relationship to patient|
|Methods utilized for assault: Weapons, physical blows, restraints, burns, strangulation, threat(s) of harm, involuntary ingestion of drugs|
|Assault Related Acts as Described by the Patient5,11|
|Oral copulation of genitals/anus|
|Non-genital acts (licking, kissing, suction injury, biting)|
|Use of foreign bodies|
|Contraception or lubricant use|
Performing the Physical Exam
Elements of the physical exam include an assessment of5,11,13:
- The patient’s general appearance/emotional status
- A complete physical examination of the head, body, and extremities with documentation of all visible injuries
- A genital examination with colposcopy for females if available
Elements of evidence collection include5,11,13:
- Swabs/smears of involved orifices
- Patient saliva samples
- Fingernail scrapings
- Packaging of patient clothing
- Head hair and pubic hair combing and collection
- External genitalia and peri-anal swabbing
- Swabbing of bodily areas soiled with blood, semen, or saliva
- Blood typing of specimens obtained
For an example of the forensic examination document sheet, see the Rosens’ text: Reference 5.
A Word on Sexual Assault Nurse Examiners (SANE)
In 2002, the International Association of Forensic Nurses (IAFN) created a certification program to: develop nurses who were experts in history-taking, treatment of trauma response and injury, documentation and collection of evidence, and the delivery of testimony required to bring sexual assault cases through the legal system.14 Today the IAFN maintains SANE education guidelines and has extended the scope of forensic nursing to include certification programs in pediatric sexual assault nursing (SANE-P vs. adult/adolescent SANE-A).15
There are currently greater than 400 SANE programs across the nation, the majority associated with major medical centers.16 (To find a program, the following search engine may be employed: http://www.forensicnurses.org/search/custom.asp?id=2100).
Why is this pertinent for emergency physicians? Although further research is required (secondary to small sample sizes, and differing definitions regarding the provision of care), studies have identified improved patient outcomes through the employment of dedicated sexual assault nurse examiners:
Sievers et al., 2003: Criminal laboratory analysts completed 515 audits of sexual assault evidence kits submitted to the Colorado Bureau of Investigation from October 1999-April 2002 (279 kits completed by SANEs, 236 completed by physicians and local nurses). As compared to physicians and local nurses, SANEs were:
- More likely to have a completed chain of custody requirements (92%) as compared to 81% of physicians/local nurses.
- More likely to have properly sealed individual specimen envelopes (91% vs. 75%).
- More likely to have labeled the individual specimen envelopes (95% vs. 88%), and to have collected the appropriate amount of pubic hair (88% vs. 74%), and head hair (95% vs. 80%).
- More frequently included the appropriate number of blood tubes (95% vs. 80%), collected the appropriate amount of swabs (88% vs. 71%), and included a vaginal fluid slide for sperm motility (87% vs. 72%).17
Campbell et al., 2005: Empirical literature review of the psychological recovery of survivors, the provision of comprehensive medical care, the documentation of forensic evidence, and the reliability of testimony during prosecution, demonstrated SANE nurses as effective in all domains. (As recognized by the authors: numerous studies reviewed lacked methodological controls).18
Interestingly, this has become a topic of debate, as some would argue that SANE nursing programs decrease resident exposure to sexual assault patients, thus limiting resident education regarding proper procedures and protocols.
In 2007, McLaughlin et al. demonstrated a knowledge deficit amongst emergency medicine residents, trained in an institution equipped with a SANE program, with respect to written knowledge regarding the sexual assault exam, collection of evidence (simulation utilizing mannequins), performance during standardized patient interviews, and documentation:
Twenty-three (85%) residents completed the study. Pre-intervention, residents scored 56% on the written knowledge test, 63% on evidence collection, 71% on standardized patient interviews, and 66% on the written note.18
After an educational intervention, McLaughlin and his colleagues noted: Residents demonstrated significant post-intervention improvements in written knowledge (improvement 24%; 95% confidence interval [CI] 20% to 27%) and evidence collection (improvement 18%; 95% CI 12% to 24%). Resident post-test scores were similar to those of SANE providers.18
Sexually Transmitted Infection (STI) and Pregnancy Prophylaxis
The likelihood of acquiring an STI after rape is difficult to predict, and varies according to the type of assault, the assailant, and geographic location. Current studies estimate the relative risk of contracting trichomonas as 12%, gonorrhea as 4-12%, and chlamydia as 2-14%.5,13,19
The Centers for Disease Control and Prevention (CDC) recommend the following prophylactic regimen in the treatment of the sexual assault patient:
Although prophylaxis for syphilis is not recommended by the CDC, previous studies report the risk of contraction post sexual assault as approaching 5%.5,13,19 Prophylaxis should be considered in areas or populations where the syphilis is prevalent. Alternatives to prophylactic treatment include the documentation of a recommendation for VDRL/antibody specific testing at a later date.13
The risk of HIV transmission from a single sexual assault is less than 0.1%.5,13 Experts recommend discussing victim and assailant risk factors (Figure 2 – Detailed in Rosen’s text), and utilizing shared decision making to determine the appropriateness of post-exposure prophylaxis (PEP).5,20
Current regimens for non-occupational post-exposure prophylaxis in adults and adolescents include21:
- Tenofovir disoproxil fumarate (300mg QD) and emtricitabine (200mg QD) +
- Raltegravir (400mg BID) or Dolutegravir (50mg QD)
- Tenofovir disoproxil fumarate (300mg QD) and emtricitabine (200mg QD) +
- Darunavir (800mg QD) + Ritonavir (100mg QD)
Note: Studies demonstrate PEP as most effective when initiated within 72 hours of exposure.20 The CDC recommends providing the patient with a one-week supply of PEP medications, and scheduling follow-up at the one-week point to discuss medication tolerance and side-effects.20 Patients electing to take PEP require interval follow-up for serial laboratory studies (antiviral therapy commonly associated with renal, hepatic, and hematologic side effects).5,20 HIV testing should be performed for all sexual assault victims at 6 weeks, 3 months, and 6 months post assault.20
The CDC recommends post-exposure hepatitis B vaccination (without HBIG) for all sexual assault patients if previously un-immunized. The hepatitis B vaccination series should be completed with subsequent doses at 1-2 months, and 4-6 months after the first injection.20
The risk of pregnancy after a sexual assault is estimated as 2-4%.11,13 Females of reproductive age should be offered pregnancy prophylaxis.20 Ovral, Lo/Ovral, and Nordette may be administered up to 72 hours post assault.11 The most common side-effect associated with these medications is nausea, therefore patients should be discharged with an anti-emetic.11 Female assault victims should be instructed to perform a pregnancy test if menstruation does not occur 3-4 weeks post treatment.11 See Figure 3 for information regarding pregnancy prophylaxis regimens.
Psychological Care & Follow-Up
Long-term sequelae of sexual assault include depression, drug and alcohol abuse, and sexual dysfunction.13 Studies indicate that up to one-third of sexual assault victims experience PTSD.13 As compared to the general population, rape victims are thirteen times more likely to attempt suicide.13,22 Experts recommend that all sexual assault victims be referred to a rape crisis center within 48 hours of evaluation.13
Medical follow-up visits should be scheduled for the sexual assault patient at 1-2 weeks, and 2-4 months for repeat STD testing, VDRL/FTA-ABS testing, and PEP monitoring as appropriate.5,13,20
Special Topic: Date Rape Drugs
The incidence of drug-facilitated sexual assault (DFSA) is increasing worldwide.5,23 Flunitrazepam (Rohypnol), gama-hydroxybutyrate (GHB), and ketamine have been heralded as the new “date rape drugs,” so let’s do a quick review:
Flunitrazepam (Rohypnol) – a benzodiazepine ten times as potent as valium, is currently available in Europe and Latin America, and is distributed as 1 or 2 mg tablets. In 1996, the U.S. FDA enacted legislation to inhibit the importation of Rohypnol secondary to concerns for abuse. Street names for flunitrazepam include: “Mexican Valium,” “circles,” “roofies,” “la rocha,” “roche,” “R2,” and “rope.” At high doses Rohypnol may cause sedation and significant respiratory depression, however, the drug is distributed in such small concentrations that supportive care is generally all that is required.26
Gama-hydroxybutyrate (GHB) – a naturally occurring fatty-acid derivative of the neurotransmitter, GABA, was originally marketed in the 1990s as a dietary supplement. Today, the over-the-counter sale of GHB has been banned due to its association with seizure-like activity and reflex autonomic activation. GHB is commonly available in oral solutions, and its delivery as such has earned it the street names of “liquid ecstasy,” “soap,” and “salty water.” Individuals ingesting GHB commonly experience symptoms of CNS depression and anterograde amnesia. Bradycardia and tonic-clonic seizures are also well-documented side-effects. Patients exposed to large concentrations often require airway support, including intubation.26
Ketamine – a derivative of phencyclidine hydrochloride (PCP), was developed in the 1960s for use as a dissociative anesthetic. Ketamine primarily interacts with NMDA receptors to inhibit the release of glutamate, but is also known to stimulate muscarinic, nicotinic, cholinergic, and opiod receptors. Ketamine is currently employed in the medical setting for procedural sedation, pain control, and for the treatment of depression, and is available under the street names of “K,” “kit-kat,” “super K,” and “jet.” Ketamine is sold as a solid or powder for users to inject, ingest, smoke, or snort. Ketamine may cause significant sympathetic activation resulting in tachycardia and hypertension, and users often experience apnea shortly after drug administration. Drug effects are much more prevalent in users who inject ketamine as opposed to ingest it (significant first pass metabolism after oral intake).26 Patients commonly require supportive care. In extreme cases, airway management may be indicated.
The Utility of Serum/Urine Screening in the Emergency Department
Forensic examination requires sampling of blood and urine if the patient endorses substance use/abuse or if he/she reports concern for drug-facilitated sexual assault.5,11 In the setting of DFSA, samples are rarely useful to the emergency medicine physician as the majority of drugs utilized are rapidly absorbed and metabolized5,25:
- The half-life of Rohypnol is reported as 10-15 hours => frequently undetectable by UDS and requiring high performance liquid chromatography or gas chromatography-mass spectrometry (GC-MS) for identification. (Flunitrazepam and its metabolites, 7-amino-flunitrazepam and norflunitrazepam, are identifiable for up to 3 days post administration by GC-MS).26
- The half-life of GHB is 20 minutes. GHB is not detectable by standard serum and urine toxicology screens due to its short half-life and its elimination through exhalation (metabolized to CO2). GC-MS will detect GHB up to 6-8 hours post administration.26
- Serum and urine tests for ketamine (and norketamine, it’s metabolite) are not available as standard laboratory sets.26
As an aside, it is important to note that ethanol remains the number one substance of choice for perpetrators of sexual assault.24,25 While published data from the U.S. is lacking, large studies from Sweden and Norway demonstrate elevated blood alcohol concentration as the number one toxicologic finding in victims of sexual assault27,28:
Hagemann et al., 2013: Retrospective, descriptive study of female patients ≥ 12 years of age presenting for evaluation post sexual assault from 2003-2010 (n=120). In total 102 patient serum samples, drawn within 12 hours of the alleged assault, tested positive for ethanol. The median blood alcohol concentration (BAC) at the time of the assault was 1.87 g/L. Patients testing positive for ethanol more often reported a public place of assault and stranger assailant.27
Jones, et al., 2012: Retrospective review of a Swedish national forensic database (TOXBASE) for female victims of sexual assault having contributed blood and urine samples, 2008-2010 (n=1406) and 2003-2007 (n=1806). In the 2008-2010 group, ethanol was detected as the only drug in 41% (603) of victims, and in the 2003-2007 group as 43% (772) of victims – significantly more prevalent than the previously mentioned date rape drugs representing 2.5% (36) and 3.2% (58) of victims.28
- Stabilize the patient as appropriate – 5% of victims require hospitalization secondary to severe injury5,8,9
- Understand your options and do what’s in the best interest of the patient:
- Call the patient advocate (state attorney’s offices will provide a list of resources if needed)
- Refer as appropriate:
- If the patient may be better served by an institution with a SANE program, then transfer
- Provide pregnancy prophylaxis as appropriate
- Provide STI prophylaxis
- Provide Hepatitis B vaccination if un-immunized
- Discuss risk factors for HIV transmission and the risks/benefits of prophylaxis
- Involve a rape crisis counselor EARLY
- Many patients experience PTSD, depression, and suicidal ideation post assault13
- Stress the importance of follow-up for STI monitoring, PEP evaluation as indicated, and continued emotional support
References / Further Reading
- Sampsel K, Szobota L, Joyce D, Graham K, Pickett W. The impact of a sexual assault/domestic violence program on ED care. J Emerg Nurs. 2009;35(4):282-289.
- Tjaden P, Thhoennes N: Extent, nature, and consequences of rape victimization: findings from the national violence against women survey. National Institute of Justice Special Report. Washington, DC: U.S. Department of Justice; 2006. Available from www.ncjrs.gov/pdffiles1/ nij/210346.pdf.
- Poirier, M. Care of the female adolescent rape victim. Pediatr Emerg Care, 2002;18:53.
- Adams J, Giradin B, Faugno D. Adolescent sexual assault: Documentation of acute injuries using photo-colposcopy. J Pediatr Adolesc Gynecol. 2001;14:174-180.
- Slaughter L. Sexual Assault. Rosen’s Emergency Medicine – Concepts and Clinical Practice. 8th ed. Chapter 67. 855-871. Elsevier Saunders. Philadelphia, PA.
- Bureau of Justice Statistics: National crime victimization survey: criminal victimization. 1998. Washington, D.C.: U.S. Dept of Justice Programs; 1999.
- Dunn S, Gilchrist V. Sexual assault: Family violence and abusive relationships. J Prim Care. 1993; 20(2):359-373.
- Kobernick M, Seifert S, Sanders A. Emergency department management of the sexual assault victim. Emerg Med Clin N Am. 1985; 2:205-214.
- Saltzman L, et al: National estimates of sexual violence treated in the emergency departments. Ann Emerg Med. 2007; 49:210-217.
- Marchbanks P, Lui K, Mercy J. The risk of injury from resisting rape. Am J Epidemiol. 1990; 132:540-549.
- McConkey T, Sole M, Holocomb L. Assessing the female assault provider. JNP. 2001; 26(7):28-41.
- Scalzo T. Rape and sexual assault reporting laws. National Center for Prosecution of Violence Against Women. Available from: https://www.evawintl.org/Library/DocumentLibraryHandler.ashx?id=571
- Linden J. Sexual assault. Emerg Med Clin N Am. 1999; 17(3):685-697.
- Speck P, Peters S. Forensics in np practice. Adv Nurse Pract. 1999;7(11):18.
- International Association of Forensic Nurses. Forensic nursing scope and standards 2015. Available from: http://c.ymcdn.com/sites/www.forensicnurses.org/resource/resmgr/Docs/SS_Public_Comment_Draft_1505.pdf?hhSearchTerms=%222015protect%20$elax%20pm%20$andprotect%20$elax%20pm%20$draft%22
- Sexual Assault Resource Service. SANE programs in the United States. Available from: http://www.sane-sart.com/
- Sievers V, Murphy S, Miller J. Sexual assault evidence collection more accurate when completed by sexual assault nurse examiners: Colorado’s experience. J Emerg Nurs. 2003; 29(6):511-514.
- Campbell R, Patterson D, Lichty L. The effectiveness of sexual assault nurse examiner (SANE) programs: a review of psychological, medical, legal, and community outcomes. Trauma Vioence Abuse. 2005;6(4):313-329.
- McLaughlin S, Monahan C, Doezema D, Crandall C. Implementation and evaluation of a training program for the management of sexual assault in the emergency department. Ann Emerg Med. 2007:49(4):489-494.
- Jenny C, Hooton T, Bowers A, et al. Sexually transmitted disease in victims of rape. N Engl J Med 322:713-716,1990
- Centers for Disease Control and Prevention. Sexual assault and STDs. 2010. Available from: http://www.cdc.gov/std/treatment/2010/sexual-assault.htm
- Centers for Disease Control and Prevention. Updates for antiretroviral postexposure prophylaxis after sexual, injection drug use, or nonoccupational exposure to HIV. 2016. Available from: https://stacks.cdc.gov/view/cdc/38856
- Kilpatrick D, Edmunds C, Seymour A. Rape in America-a report to the nation. Crime Victim Research and Treatment Center. Charleston, SC, Medical University of South Carolina, 1992.
- Du Mont J, Macdonald S, Rotbard N, Asllani E, Bainbridge D: Factors associated with suspected drug facilitated sexual assault. CMAJ 2009; 180:513-519.
- Dinis-Oliveira R, Magalhaes T. Forensic toxicology in drug-facilitated sexual assault. Toxicol Mech Methods. 2013:23(7):471-478.
- Jones A, Kugelberg F, Holmgren A, Ahlner J. Occurrence of ethanol and other drugs in blood and urine specimens from female victims of alleged sexual assault. Forensic Sci Int. 2008;181:40-46.
- Smith K, Larive L, Romanelli F. Club drugs: methylenedioxymethamphetamine, flunitrazepam, ketamine hydrochloride and gama-hydroxybutyrate. Am J Health-Syst Pharm. 2002;50(1):1067-1076.
- Hagemann C, Helland A, Spigset O, Espnes K, Ormstad K, et al. Ethanol and drug findings in women consulting a sexual assault center-associations with clinical characteristics and suspicions of drug-facilitated sexual assault. J Forensic Leg Med. 2013;20:777-784.
- Jones A, Holmgren A, Ahlner J. Toxicological analysis of blood and urine samples of victims of alleged sexual assault. J Clin Toxicol. 2012;50:555-561.