Sexual Assault Medical And Legal Implications Of The Emergency Care Of Adult Victims
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Sexual Assault Medical And Legal Implications Of The Emergency Care Of Adult Victims

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Table of Contents
 
Table of Contents
  1. The Critical Appraisal Of The Literature
  2. Epidemiology
    1. Lack Of Reporting
    2. Lack Of Medical Care
  3. Enhancing Medical Care
    1. The Sexual Assault Nurse Examiner
  4. Prehospital Care
  5. Emergency Department Evaluation
    1. History
    2. Physical Examination
      1. Evidence Collection Examination Evidence Collection Kits
      2. Appropriate Evidence Collection/Documentation
      3. Injuries Associated With Sexual Assault
      4. Macroscopic Visualization Of Genital Injuries
        • Significance Of Trauma
        • Augmented Examination
        • Colposcopy
        • Anoscopy
        • Toluidine Blue
      5. Forensic Evidence Collection
        • Hair
        • Fingernail Scrapings
        • Blood And Saliva
        • Sperm And Seminal Products
        • Wood's Lamp
        • Sperm Motility
        • Fluorescence In Situ Hybridization
        • DNA Profiling
  6. Treatment
    1. Sexually Transmissible Diseases
      1. STD Prevalence
      2. STD Testing
      3. STD Treatment/Prophylaxis
    2. STD Follow-up Care
    3. Human Immunodeficiency Virus
      1. HIV Risk
      2. HIV Testing
      3. HIV Counseling
      4. HIV Postexposure Prophylaxis
    4. Prevention Of Pregnancy
  7. Special Considerations
    1. Male Sexual Assault
    2. Drug-Facilitated Sexual Assault
      1. Alcohol
      2. Flunitrazepam
      3. Ketamine
      4. Gamma Hydroxybutyrate
    3. Emotional And Psychological Impact Of Rape
    4. Legal Prosecution
  8. Discharge And Follow-Up
  9. Summary
  10. Key Points
  11. Sexual Assault Survivors Therapeutic Message
  12. The Common Myths And Misconceptions About Sexual Assault
  13. Time-Effective Approaches For Sexual Assault
  14. Clinical Pathway:Sexual Assault Evidence Collection
  15. Tables and Figures
    1. A Comparison Of National Estimates Of The Incidence Of Rape In the United States
    2. Prophylaxis Recommendations for Sexual Assault Victims
    3. Macroscopic Visualizations of Genital Injuries
  16. References

The Critical Appraisal Of The Literature

The literature on sexual assault is vast and detailed. Most of the literature on sexual assault involves case series and cohort studies. Few studies approach the topic in a formal prospective fashion.

Multiple studies have revealed the epidemiology behind the patients we evaluate in the ED with the complaint of sexual assault. How, when, and why we collect evidence also has undergone review, however,with mixed results. The specific topics will be further discussed in the sections to follow. Two very important areas of sparse literature include patterns of genitorectal injury seen in nonconsensual sexual intercourse as well as the use of post exposure prophylaxis for HIV in the setting of sexual assault. In addition, only a few studies have addressed the successful prosecution of sexualassault cases as a result of the documentation and collection of evidence done while the patient is evaluated in the ED. This is an important outcome measure we must evaluate to ensure the best possible care for these victims.

Several national guidelines exist, most notably the 2002 national guidelines on the management of adult victims of sexual assault from the Association for Genitourinary Medicine/Medical Society for the Study of Venereal Diseases 3as well as the 2002 sexually transmit-ted diseases treatment guidelines from the Centers for Disease Control and Prevention (CDC).4Most states have standardized guidelines for evidence collection in the case of sexual assault

Epidemiology

About 96% of sexual assault victims are female.Because women comprise the majority of sexual assault cases,this article refers to sexual assault victims as female.However, it is important to note that up to 2%-12% of males have been sexually assaulted, as discussed later in this article.6,7 In the early 1990s, sexual assault incidence increased four times as fast as the overall crime rate in the United States, with a woman being sexually assaulted once every six minutes.In 1994, the overall violent crime rate in the United States began to decline, and the incidence of sexual assault also declined by about 37%.In 2000, 50sexual assaults per 100,000 were reported to law enforcement.However, based on the National Crime Victimization Survey (a national random digit dial telephone survey), significantly more people experienced sexual assault. The survey reported assault rates ranging from332 per 100,000 in 1992 to 160 per 100,000 in 1998.(See also Table 1.) Although the numbers of sexual assault cases in the United States may be declining, a woman is still sexually assaulted every 8.2 minutes.10 The problem is very real and continues to affect a hug esegment of our population.

Death from sexual assault is unusual. In one retrospective review in Dade County, Florida, the average yearly incidence of fatal sexual assaults on females was calculated to be 0.14/100,000. The most common cause of death was mechanical asphyxiation, usually manual strangulation.11 Rape/homicides represent only 1% of all cases of sexual assault.12

Lack Of Reporting

Rape has been termed the silent violent epidemic. The majority (84%) of rape victims never report the crime to police, and of those who do report, only 12% report the rape within 24 hours of the actual assault.While estimates vary, another similar study concluded that only a third of sexual assault victims report the crime to law enforcement.10 While police reports of sexual assault greatly underestimate the true incidence of the crime,other tools such as the National Crime Victimization Survey better reflect the actual incidence.(See Table 1.)

One study revealed that a rape victim was nine times more likely to receive timely medical care if she reported the assault to the police or other authorities. Three out of four victims in this study who reported the rape to police received medical care, whereas only 15% of rape victims who did not report the crime received post-rape medical care.13

Lack Of Medical Care

Findings show that over 4 million U.S. women have survived a rape as an adult but never received post-assault medical attention. Furthermore, many who did seek care were too late to benefit from STD and pregnancy prophylaxis.13

According to a survey with more than 3000 respondents, only two-thirds of victims who received post-rape care did so within 48 hours of the assault. An additional21.4% sought care within the first week, and 12% did so more than one month after the assault. In only 59% of cases did the victim inform the health care provider that asexual assault had occurred.13

Sexual assault victims choose not to seek care for many reasons. Factors that decrease the likelihood of seeking care include Caucasian race, younger age, the use of drugs or alcohol, and having a known assailant.Reasons patients give for not seeking medical care include fear of being disbelieved, retaliation, societal stigmatization, and public disclosure. An overall distrust of doctors and the legal system further decreases the likelihood of seeking immediate post-assault medical or legal assistance. Being Hispanic, Native American, or having an unknown assailant increases the likelihood of reporting. Reasons for seeking early medical care include traumatic injuries and fear of STDs and HIV.13,14

The majority of sexual assaults are committed by an individual known to the victim.13 Sexual assault by an acquaintance is as traumatic as the classic "blitz" or stranger assault. The National Women's Study showed that 29% of assailants are acquaintances; 11%, stepfathers;10%, boyfriends; 9%, ex-husbands; and 16% are other relatives. Only 22% are assaults by strangers.8

While fear of STDs and HIV is less in women who suffer acquaintance sexual assault, the actual rates of STDs in this cohort are still high. The STD rates among the abused, assaulted, and raped victims who are acquainted with their assailant are 29%, 31%, and 31.3%,respectively—which is significantly higher than in a cohort of non-abused women.15

Tables and Figures

A Comparison Of National Estimates Of The Incidence Of Rape In the United States

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust.The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such asthe type of study and the number of patients in the study,will be included in bold type following the reference,where available. In addition, the most informative references cited in the paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.

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  2. No authors listed. Management of the patient with the complaint of sexual assault. American College of Emergency Physicians. Ann Emerg Med 1995 May;25(5):728-729. (Policy statement)
  3. Association for Genitourinary Medicine (AGUM), Medical society for the Study of Venereal Disease (MSSVD). 2002national guidelines on the management of adult victims of sexual assault. London: Association for Genitourinary Medicine (AGUM), Medical Society for the Study of Venereal Disease (MSSVD); 2002. (Guideline)
  4. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR Morb Mortal Wkly Rep 2002:51 (No. RR-6):1-80. (Guideline)
  5. Rennison CM. Criminal Victimization 2000. Washington, DC:U.S. Department of Justice; 2001. (Crime statistics)
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  7. Bureau of Justice Assistance. Testing Certain Offenders for HIV:Guidance of States on Section 1804 Requirements. Washington, DC:Office of Justice Programs, U.S. Department of Justice; 1992:1-7.(Epidemiologic data and guidelines)
  8. National Center for Victims of Crime and Crime Victims Research and Treatment Center. Rape in America: A Report to the Nation. Arlington, VA: National Center for Victims of Crime and Crime Victims Research and Treatment Center; 1992.(Epidemiologic data)
  9. No authors listed. Priority area 7: Violent and abusive behavior.Healthy People 2000 Final Review. Washington, DC: U.S.Department of Health and Human Services; 2000. (Crime statistics)
  10. Greenfeld LA. Sex Offenses and Offenders: An Analysis of Data on Rape and Sexual Assault. Washington, DC: U.S. Department of Justice; 1997. (Crime statistics)
  11. Deming JE, Mittleman RE, Wetli CV. Forensic science aspects of fatal sexual assaults on women. J Forensic Sci 1983;28:572-576.(Retrospective; 41 patients)
  12. Petter LM, Whitehill DL. Management of female sexual assault.Am Fam Physician 1998;58:920-930. (Review)
  13. Resnick HS, Holmes MM, Kilpatrick DG, et al. Predictors of post-rape medical care in a national sample of women. Am JPrev Med 2000 Nov;19:214-219. (Two-year longitudinal survey;3006 respondents)
  14. Sachs CJ, Chu LD. Predictors of genitorectal injury in female victims of suspected sexual assault. Acad Emerg Med 2002;9:146-151. (Retrospective; 209 patients)
  15. Campbell JC, Woods AB, Chouaf KL, et al. Reproductive health consequences of intimate partner violence. A nursing researchreview. Clin Nurs Res 2000;9:217-237. (Review)
  16. Resnick H, Acierno R, Holmes M, et al. Emergency evaluation and intervention with female victims of rape and other violence. J Clin Psychol 2000;56:1317-1333. (Epidemiologic review)
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  34. * Linden JA. Sexual assault. Emerg Med Clin North Am1999;17:685-697. (Review)
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  38. * McGregor MJ, Le G, Marion SA, et al. Examination for sexualassault: is the documentation of physical injury associated withthe laying of charges? A retrospective cohort study. CMAJ1999;160:1565-1569. (Retrospective; 95 patients)
  39. Biggs M, Stermac LE, Divinsky M. Genital injuries followingsexual assault of women with and without prior sexualintercourse experience. CMAJ 1998;159:33-37. (Retrospective;132 patients)
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  42. * Slaughter L, Brown CR, Crowley S, et al. Patterns of genitalinjury in female sexual assault victims. Am J Obstet Gynecol1997;176:609-616. (Prospective; 311 patients)
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  44. Lenahan LC, Ernst A, Johnson B. Colposcopy in evaluation ofthe adult sexual assault victim. Am J Emerg Med 1998;16:183-184. (Prospective; 17 patients)
  45. O'Brien C. Improved forensic documentation of genital injurieswith colposcopy. J Emerg Nurs 1997;23:460-462. (Review)
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  48. Lauber AA, Souma ML. Use of toluidine blue for documenta-tion of traumatic intercourse. Obstet Gynecol 1982;60:644-648.(Prospective; 44 patients)
  49. * McCauley J, Guzinski G, Welch R, et al. Toluidine blue in thecorroboration of rape in the adult victim. Am J Emerg Med1987;5:105-108. (Prospective; 24 patients)
  50. Slaughter L, Brown CR. Colposcopy to establish physical findings in rape victims. Am J Obstet Gynecol 1992;166:83-86.(Review; 131 patients)
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  62. Silverman EM, Silverman AG. Persistence of spermatozoa inthe lower genital tracts of women. JAMA 1978;240:1875-1877.(Prospective; 675 patients)
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  64. Graves HC, Sensabaugh GF, Blake ET. Postcoital detection of amale-specific semen protein. Application to the investigation ofrape. N Engl J Med 1985;312:338-343. (Prospective; 29 patients)
  65. Rao PN, Collins KA, Geisinger KR, et al. Identification of maleepithelial cells in routine postcoital cervicovaginal smearsusing fluorescence in situ hybridization. Application in sexualassault and molestation. Am J Clin Pathol 1995;104:32-35.(Prospective; 40 patients)
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  86. * Bamberger JD, Waldo CR, Gerberding JL, et al. Postexposureprophylaxis for human immunodeficiency virus (HIV)infection following sexual assault. Am J Med 1999;106:323-326.(Review)
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  93. Nielsen CL, Miller L. Ectopic gestation following emergencycontraceptive pill administration. Contraception 2000;62:275-276.(Case report)
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  98. White SR. Date rape drugs. Part I. Featured article onemedhome.com, June 12, 2000. (Review)
  99. ElSohly MA. Drug-facilitated sexual assault. South Med J2001;94:655-656. (Review)
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  105. No authors listed. Schedules of controlled substances: additionof gamma-hydroxybutyric acid to schedule I. Federal Register2000 March 13;65(49):13235-13238. (Listing)
  106. White SR. Date rape drugs. Part II. Featured article onemedhome.com, June 19, 2000. (Review)
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  113. * Gray-Eurom K, Seaberg DC, Wears RL. The prosecution ofsexual assault cases: correlation with forensic evidence. AnnEmerg Med 2002;39:39-46. (Retrospective; 801 patients)
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  116. Groth AN, Burgess AW. Sexual dysfunction during rape. NEngl J Med 1977;297:764-766. (Review)

 

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Authors

Teresita M. Hogan; Amy Archer Uyenishi

Publication Date

March 1, 2003

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