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Emergency and Acute Medicine - Sexual Assault
Sexual assault refers to a range of nonconsensual sexual acts, including attempted or completed penetration (vaginal, anal, or oral), penetration with objects, and intentional touching of genital or intimate areas. Legal definitions vary by jurisdiction, but all forms involve lack of consent. Sexual assault is a significant public health issue, with a lifetime prevalence of approximately 18% in women and 5% in men. Most female victims know their assailant, whereas male victims are more often assaulted by strangers or acquaintances. Risk is higher among vulnerable populations, including individuals with disabilities, those experiencing intimate partner violence, and certain high-risk groups such as prisoners or individuals seeking mental health care.
Victims may present with a wide range of physical and psychological symptoms, and many do not initially disclose the assault unless directly asked. Common complaints include headaches, nausea, abdominal pain, sleep disturbances, anxiety, and breathing difficulties. Physical injuries may be absent in up to 70% of cases, but when present, may include genital trauma, lacerations, contusions, abrasions, bite marks, or more severe injuries such as fractures or burns. In pediatric cases, most physical examinations are normal, and evaluation must follow legal child protection requirements. Pregnancy increases vulnerability to assault, and special considerations apply.
A thorough and sensitive history is essential and should be obtained even if the patient does not wish to involve law enforcement. Important details include timing and location of the assault, number and description of assailants, type of contact or penetration, use of force or substances, and activities since the assault (e.g., bathing, changing clothes). A complete medical and gynecologic history should also be obtained. The physical examination should be conducted with informed consent, respecting the patient’s comfort and pace, and ideally performed by a trained sexual assault examiner (SANE) if available. Documentation should include the patient’s emotional state, clothing condition, and any physical injuries. Forensic evidence collection may include clothing, swabs, hair samples, and fingernail scrapings, following strict protocols to preserve evidence.
Laboratory evaluation may include testing for sexually transmitted infections such as gonorrhea, chlamydia, syphilis, hepatitis B and C, and HIV, as well as pregnancy testing. Drug screening may be considered if drug-facilitated assault is suspected. Imaging and additional procedures are guided by the presence of injuries.
Management begins with ensuring patient safety, privacy, and a supportive, nonjudgmental environment. Life-threatening injuries must be addressed first. Patients should be placed in a quiet setting and offered access to an advocate or support person. Confidentiality should be emphasized, and the patient’s autonomy respected regarding reporting to law enforcement, unless mandated by local laws.
Preventive treatment is a key component of care. Emergency contraception should be offered within 72 hours if there is a risk of pregnancy. Prophylactic treatment for sexually transmitted infections is recommended, typically including antibiotics for gonorrhea, chlamydia, and trichomonas. Hepatitis B vaccination should be initiated if the patient is not immunized, and HIV post-exposure prophylaxis should be considered within 72 hours for high-risk exposures. Baseline laboratory tests should be obtained if HIV prophylaxis is started.
Disposition depends on the patient’s physical and psychological condition. Admission is required for serious injuries, while most patients can be discharged with appropriate follow-up. Follow-up care includes repeat HIV testing at 6 weeks, 3 months, and 6 months, as well as monitoring for medication side effects. Referral for mental health support and counseling is essential. Pediatric cases require involvement of child protective services.
A key challenge in managing sexual assault is underreporting, as many victims do not disclose the event unless directly asked. Extragenital injuries are often more common than genital findings, and normal examination does not exclude assault. The use of specialized forensic examiners improves the quality of care, evidence collection, and patient outcomes.
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