Sexual violence

Sexual violence is any nonconsensual sexual act. Sexual crimes are underreported in the US because of stigma, fear, and the fact that perpetrators are often close acquaintances (e.g., partners) and/or individuals in positions of authority over the person experiencing the violence (e.g., guardians, teachers, religious officials). Individuals who have experienced sexual violence may have physical injuries (e.g., bruises, lacerations, injuries to the genital, anal, and/or oral areas), symptoms of psychological trauma (e.g., intrusive thoughts, flashbacks, sleep disturbances, nightmares), or no apparent injury. Whenever possible, providers with advanced training, e.g., sexual assault response teams, should care for individuals who have experienced sexual violence. Evaluation includes a thorough examination for injuries and collection of forensic evidence using a sexual assault forensic evaluation kit (SAFE kit; colloquially referred to as a “rape kit”). Individuals may undergo STI, toxicology, and/or pregnancy testing. Management may include STI prophylaxis, emergency contraception, and/or referral for psychological counseling. Long-term effects of sexual violence may include PTSD, depression, anxiety, sexual dysfunction, and substance use disorders.

Management of intimate partner violence in general is detailed separately.

Sexual violence

Sexual violence is the use of physical or psychological force during or as a means to obtain a sexual act from another individual. Although specific definitions of the types of sexual violence vary between jurisdictions, sexual violence is generally considered a crime if committed against a nonconsenting individual.

Sexual consent

• Definition: voluntary and discernible approval by a legally and functionally competent individual to engage in a sexual activity proposed or initiated by another individual
• Age of consent: age at which an individual is legally permitted to engage in sexual activity
• Inability to consent: the inability to voluntarily and discernibly approve a sexual contact as a result of mental or physical disability or another illness, being asleep or unconscious, being too intoxicated (whether voluntarily or involuntarily so), or being below the age of consent
• Inability to refuse: the inability to express nonconsent as a result of physical violence, the threat of force, or other forms of coercion or intimidation (e.g., misuse of authority)

Sex crimes ^[1]

• Unwanted sexual contact
  • The unwanted touching of a nonconsenting person or a person unable to consent or refuse in a sexual manner, especially of the genitalia, anus, breasts, inner thigh, or buttocks
  • Unwanted sexual contact in a social setting may be considered sexual harassment.
• Sexual harassment: a form of sexual discrimination in any social setting (e.g., workplace, school, church) that involves any type of unwanted sexual advances, the request of sexual favors, or any other type of sexual verbal and/or physical conduct that creates an abusive or hostile environment
• Sexual assault
  • Any nonconsensual sexual act ranging from unwanted touching to rape; includes sexual acts upon persons lacking the capacity to give consent
  • Definitions vary between jurisdictions but typically cover nonconsensual sexual acts involving:
    • The use of force, the threat of force, coercion, or abuse of authority to obtain a sexual act
    • Touching, groping, and kissing
    • Exhibitionism
    • Exposure to pornographic materials
    • Individuals below the age of consent
    • The use of drugs or alcohol for incapacitation or manipulation
• Rape: the nonconsensual penetration of another person's vagina, anus, or mouth with any body part or object
  • Attempted rape: the clearly intended but unsuccessful attempt to penetrate another person's vagina, anus, or mouth with any body part or object without their consent
  • Statutory rape: sexual intercourse with a person below the age of consent, regardless of whether the act occurred against the person's will
• Child sexual abuse: any sexual act, including sexual assault, rape, incest, and exploitation (i.e., noncontact sexual activities such as photoshoots), toward an individual under the age of consent
  • Child sexual abuse may be, but is not necessarily, motivated by pedophilic disorder.
  • See also “Child sexual abuse.”

Other terminology

• Violence
  • The threatened or actual use of force to inflict physical, psychological, and/or financial harm
  • Violent acts include assault, harassment, intentional neglect, and deprivation.
  • Physicians have a legal obligation to report certain violent crimes such as child maltreatment and older adult abuse.
• Assault
  • Any act of physical violence against another person with the intent to cause physical harm or any act that puts another person in fear of imminent physical harm
  • Assault is governed by state law in the US.
• Harassment
  • Sustained and/or systematic unwanted and unwelcome actions that annoy, threaten, intimidate, or alarm another person
  • Harassment is governed by state law in the US.
• Abuse
  • A nonlegal term referring to the physical and/or psychological mistreatment of another person
  • Usually implies a close and/or long-term relationship between the perpetrator and the person experiencing the abuse
• Maltreatment or mistreatment
  • Nonlegal terms sometimes used synonymously with abuse
  • Sometimes used in distinction to describe the quality of care (e.g., financial mistreatment or child maltreatment as a form of neglect) vs. the quality of injuries (child abuse as a form of physical and psychological violence)
• Individual who has experienced violence or survivor
  • Preferred terms for persons who have experienced acts of violence, replacing the obsolete term “victim,” which implies a state of helplessness, perpetuating the stereotype of being unable to recover from the experience
  • The term “survivor” has become very popular in recent years, but it is not unproblematic as it implies recovery from the experience as well as the threat of death, neither of which is necessarily given in all experiences of violence.

• Sex crimes are among the most unreported crimes in the US.
• Percentages of persons who have experienced rape or attempted rape in their lifetime
  • Estimated 20% (1 in 5) of all women
  • Estimated 3% (1 in 33) of all men
• Percentages of women who have experienced other types of sexual violence ^[2]
  • Sexual coercion: 12.5%
  • Unwanted sexual contact: 27.3%
  • Unwanted noncontact sexual experiences: 32.1%
• Percentages of men who have experienced other types of sexual violence
  • Made to penetrate another person: 6.7%
  • Sexual coercion: 5.8%
  • Unwanted sexual contact: 10.8%
  • Unwanted noncontact sexual experiences: 13.3%
• The most commonly affected age group is 16–25-year-olds.
• Perpetrators of sexual violence are most commonly men.
• Sexual violence is most often perpetrated by an intimate partner or acquaintance.

References:^[1][3][4]

Epidemiological data refers to the US, unless otherwise specified.

• Genital, anal, and/or oral injuries (e.g., lacerations, bruising)
• Clinical features of strangulation ^[5][6]
• Genital, pelvic, and/or abdominal pain
• Musculoskeletal injuries
• Facial injuries
• Signs and symptoms of STIs
• Acute stress reaction: Symptoms may persist for days to months.
  • Acute eating disturbances, anorexia
  • Fear, anger, anxiety, shame, guilt, embarrassment
  • Intrusive thoughts, flashbacks
  • Sleep disturbances, nightmares

The absence of visible physical examination findings does not rule out sexual violence. ^[6]

Clinical evaluation

Includes assessing the patient's immediate medical and emotional requirements, the need for STI postexposure prophylaxis and/or emergency contraception, and determining whether to proceed with a formal forensic evaluation ^[5]

History

• Goal: to gather information about the attack and relevant medical and personal history
  • Attack
    • Time, location, and setting of the attack
    • Details of the assault (e.g., extragenital acts, use of physical force or weapons, use of condoms)
    • Obtain a description or, if possible, establish the identity of the perpetrator(s).
    • Patient's ability to consent to the sexual activity at the time of the attack and details of any substance use beforehand
    • Details of the period after the assault (e.g., whether they changed their clothes, bathed, douched, brushed their teeth, urinated)
  • Relevant medical history
    • Time of last sexual intercourse
    • Immunization history and current medications
    • For patients of reproductive age: pregnancy status and last menstrual period
    • History of anogenital surgery
• Method
  • Use open-ended questions rather than yes-or-no or leading questions, e.g.:
    • “Can you tell me in your own words what happened?” rather than “Did the attack occur at night?”
    • “Can you describe the perpetrator?” rather than “Do you know the man who raped you?”
  • Avoid interrupting the patient and allow them to narrate the experience freely.
  • Document the patient's statements verbatim and avoid paraphrasing.

Physical examination ^[5][7]

Prioritize the medical evaluation and stabilization over the forensic evaluation. ^[5]

• Perform a primary survey and secondary survey in severely injured patients. ^[6][7]
• Assess for signs of strangulation. ^[5]
• Coordinate the examination (including gynecological examination) with a sexual assault nurse examiner (SANE) or sexual assault forensic examiner (SAFE).

Laboratory studies ^[6]

• STI testing: Consider on an individual basis. ; ^[5]
  • Vaginal and/or rectal smears to test for Neisseria gonorrhoeae and Chlamydia trachomatis
  • Saline wet mount of vaginal smear to test for Trichomonas vaginalis
  • Serologic testing for HIV, hepatitis B, and syphilis
  • Perform further testing based on individual risk factors.
• Comprehensive toxicology testing: if drug-facilitated sexual assault is suspected
  • Samples should be collected as soon as possible, as commonly used agents have a short half-life.
  • Red flags for drug-facilitated sexual assault
    • Unexplained loss of consciousness
    • Unexplained loss of motor control
    • Amnesia or a confused state at the time of the suspected sexual assault
    • Individual suspects that they were drugged
• Pregnancy test: Offer to all female patients of reproductive age.
• Baseline blood studies : if HIV prophylaxis is to be given

Imaging

• Head and neck CTA: if there are clinical features of strangulation ^[5]
• Other studies guided by the history and physical examination

Initial management ^[5][6]

Use a trauma-informed approach to minimize retraumatization (see “Trauma-informed communication”).

• Wear gloves to avoid contamination of evidence.
• Attempt to speak to the patient in private with a chaperone.
• Obtain informed consent for every step of management and forensic evaluation.
• Perform a primary survey to identify and treat life-threatening or limb-threatening injuries.
• Inform the sexual assault response team or facilitate transfer to a local rape crisis center.
• Offer to move stable patients to a quiet room.
• Coordinate clinical evaluation with a sexual assault nurse examiner (SANE) or a sexual assault forensic examiner (SAFE).
• Follow local protocols for preparing accurate medical documentation for potential criminal proceedings.

Care setting ^[5][6]

• The most appropriate care setting is the emergency department or local rape crisis center, as they have health care providers with advanced training in sexual assault care, e.g., sexual assault response teams (SARTs).
• In settings other than the emergency department or local rape crisis center:
  • Facilitate immediate transfer to the nearest emergency department or local rape crisis center.
  • Advise the patient to abstain from activities that can potentially destroy or alter evidence before forensic evaluation takes place.

Consider transferring individuals who have been sexually assaulted to a facility with a SART if there is not one available at the initial institution. ^[5]

Treatment

Treatment of recent sexual violence (i.e., within 72 hours) depends on the degree of physical and/or psychological trauma, the individual's age, and other individual circumstances.

STI prophylaxis ^[6][8][9]

For children, empiric prophylaxis is not routinely recommended without testing. ^[6]

• All adults and adolescents (children excluded): empiric treatment of gonorrhea and chlamydia ^[8]
  • Ceftriaxone ^[8]
  • PLUS doxycycline ^[8]
  • PLUS metronidazole (for women only; to treat trichomoniasis) ^[8]
• HIV postexposure prophylaxis: Consider based on individual risk factors. ^[9]
• Hepatitis B postexposure prophylaxis: Offer to unvaccinated individuals. ^[8]

Emergency contraception ^[5][6][10]

• Offer testing and emergency contraception to female patients of reproductive age.
• Obtain a urine or serum pregnancy test prior to administration of emergency contraception.
• Types of contraception
  • Hormonal: levonorgestrel OR ulipristal acetate ^[6][8]
  • Intrauterine device

Psychological counseling

Sexual assault that does not cause physical harm can still cause severe psychological trauma with potentially severe consequences (e.g., increased risk of suicide) and should be managed accordingly. ^[1][6][11]

• Offer referral to a psychiatrist, social worker, or rape crisis advocate.
• Provide information on sexual assault crisis programs.

Reporting ^[5][6]

Laws for reporting sexual assault vary across states and jurisdictions. There may be specific local reporting requirements if the affected individual wants to apply for reimbursement of medical therapies after sexual assault. ^[9]

• Adults: Patient consent is required to report sexual assault to law enforcement authorities in most states.
  • Adults should be asked if they would like the assault reported.
  • Inform the affected individual if reporting is mandatory.
• Minors: All states require sexual assault of minors to be reported to law enforcement authorities or Child Protective Services.
• Older adults and vulnerable adults: See “Older adult abuse.”

In the US, the National Sexual Assault Telephone Hotline can be contacted by calling 800.656.HOPE (4673) or visiting online.rainn.org.

Disposition ^[5][6]

• Consider hospital admission if:
  • Suspected strangulation with persistent symptoms
  • No safe postdischarge destination
• Prior to discharge:
  • Coordinate with the SART.
  • Give safety net advice.
• Encourage follow-up in 1–2 weeks to:
  • Repeat STD screening (gonorrhea, chlamydia, trichomoniasis) if no empiric antibiotic treatment was administered
  • Complete the vaccination series
  • Repeat the pregnancy test in female patients of reproductive age
  • Assess psychological status and how the patient is coping with the trauma

Arrange follow-up care with the same physician or another appropriate provider, e.g., a primary care provider, mental health specialist, and/or a rape crisis center.

Follow local and state laws and institutional protocols for reporting sexual assault.

General principles

• Involves taking a history related to the sexual assault, physical examination, collection of evidence, and thorough documentation
• Should only be performed by trained professionals (e.g., SANEs, SAFEs)
• Evidence should be collected with urgency (ideally within 72 hours of the assault).

Consent and patient rights

Patient consent is required for forensic examination, evidence collection, and reporting the assault to law enforcement. Thoroughly explain the examination process to obtain informed consent.

• Inform the patient about their right to the following:
  • Right to a forensic evaluation, irrespective of their decision to report the sexual assault
  • Right to refuse a forensic evaluation or decline any part of the examination or alter their consent
• Patients with temporary impairment (e.g., intoxicated or unconscious patients)
  • Postpone forensic evaluation if the patient is expected to recover within the evidence collection window.
  • If recovery time exceeds the evidence collection window, forensic evaluation can occur without consent, but release of the sexual assault forensic evidence kit to authorities requires patient consent or a court order.
• Incapacitated patients or minors (e.g., comatose patients, patients with dementia): A surrogate can consent if there is no suspicion that they were involved in the assault.

Evidence collection ^[6]

• Method: use of sexual assault forensic evidence kits
  • Kits contain all required instructions, standardized forms for documentation of examination findings, and evidence collection equipment (e.g., bags for the patient's clothing, comb used to collect hair and fiber samples from the patient, materials for swabs).
  • Kits must be sealed and stored at the medical facility and the chain of custody of evidence material must be maintained.
  • Kits are only transferred to law enforcement if the patient wants to take legal action.
• Procedure
  • Avoid cross-contamination of evidence (e.g., by using gloves and changing gloves as needed).
  • Request the patient to undress over a clean hospital sheet and collection papers and to place each piece of clothing in separate paper bags.
  • Perform a thorough examination for physical injuries (e.g., bite marks, strangulation marks) and collect biological samples that may help identify the perpetrator (e.g., semen, blood, saliva, fingernail scrapings, hairs).
    • Toluidine blue dye can be used to visualize injuries in the genital or anal region.
    • The speculum used for vaginal examination should be lubricated with tap water, not gel-based lubricants.
    • Speculum examination on prepubertal children should be performed under general anesthesia.
  • Document examination findings, their exact location, and appearance in writing and with photographs.
  • Collect, seal, and label biological specimens and foreign debris using equipment from the sexual assault forensic evidence kits.
    • Moist specimens should be collected with a dry swab.
    • Dried-out samples should be rehydrated with a wet swab and then collected with a dry swab.
    • Debris should be scraped and collected in a paper bindle.
  • After the specimens and debris have been collected, photograph the areas from which they were collected.
  • If a drug-facilitated sexual assault is suspected:
    • Collect blood and urine specimens if the drug is suspected to have been ingested within the past 36 hours.
    • Collect urine specimens if the drug is suspected to have been ingested more than 36 hours ago.
    • Do not pack these blood and/or urine specimens together with the sexual assault forensic evidence kit.
      ^[12]

• Obtain informed consent for every management step.
• Notify the sexual assault response team.
• Perform a thorough examination to assess for injuries.
• Evaluate for signs of strangulation.
• Establish the time of the assault.
  • Forensic evaluation can be performed up to 7 days after the assault.
  • Vaginal samples can be collected up to 5 days after the assault.
  • Toxicology samples can be collected up to 3–4 days after the assault.
• Consider STI and toxicology testing.
• Offer prophylactic treatment for STIs.
• Consider HIV and HBV postexposure prophylaxis.
• Offer a pregnancy test and emergency contraception.
• Offer referral to a mental health provider, rape crisis center, and/or social services.
• Report all cases of child sexual abuse (mandatory) and cases of sexual violence in adults if they consent to reporting.

• PTSD: Sexual assault is one of the most common causes of PTSD in both men and women.
• Anxiety disorders
• Depression
• Chronic pelvic pain
• Sexual dysfunction
• Substance use disorders (e.g., sedatives, stimulants, analgesics)

We list the most important complications. The selection is not exhaustive.

STOP SV strategy ^[2]

• Definition: A technical package developed by the CDC to prevent sexual violence, mitigate its effects, address its social determinants, and facilitate access to services for individuals who have experienced violence
• Elements
  • S: Promote social norms that inhibit violence (e.g., educating children and mobilizing men and boys to become allies against sexual violence).
  • T: Teach skills to prevent sexual violence (e.g., teaching safe dating and healthy intimate relationship skills, promoting healthy sexuality).
  • O: Provide opportunities to empower and support girls and women (e.g., strengthen economic support for families and facilitate leadership opportunities).
  • P: Create protective environments (e.g., monitoring in schools, addressing community-level risks, improving safety).
  • SV: Support patients who have experienced violence to reduce harm (e.g., support centers, medical treatment, and support for at-risk families).