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
About 96% of sexual assault victims are female.5 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.8 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%.5 In 2000, 50sexual assaults per 100,000 were reported to law enforcement.5 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 1998.9 (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
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.5 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.5 (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
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
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.