Sexual Assault Evaluation

Issues of Concern

Sexual assault evaluation involves numerous challenges that require careful consideration. These concerns include understanding the definitions of sexual assault, the epidemiology, and the limitations of current evaluation methods. Understanding these issues is critical for providing comprehensive and trauma-informed care.

Trauma-Informed Care

Trauma, as defined by the Substance Abuse and Mental Health Services Agency, can be experienced as violence, abuse, neglect, loss, war, and other emotionally or physically harmful experiences. These traumatic events may lead to lasting adverse effects on an individual's well-being and health. A global study led by the World Mental Health Consortium found that 70% of adults experienced at least 1 traumatic event in their lives, and 30% of adults experienced 4 or more.[5] Trauma can be individualized, interpersonal, societal, structural, or geographical. The primary causes and sequelae of experienced trauma are often witnessed in the emergency department in the form of motor vehicle accidents, fatal heart attacks, gun violence, sexual assault, physical assault, fatal overdoses, death by suicide, and more.

Trauma-informed care is an educational framework designed to better understand and mitigate the downstream effects of trauma in patient care.[6] This approach involves recognizing the power imbalance between healthcare providers and patients and collaborating to create a care plan based on the patient's desires, capabilities, and history.[1] Implementing a trauma-informed approach when caring for patients with both mental and physical ailments addresses these trauma-associated sequelae more effectively, thereby minimizing the potential for retraumatization and harm.[2]

Definitions of Sexual Assault

Terminology defined by the CDC includes the following:

• Contact sexual violence: A combined measure including rape, being made to penetrate another (completed or attempted) without the survivor's/penetrator's consent, sexual coercion, or unwanted sexual contact.

• Rape: Any completed or attempted unwanted vaginal (for women), oral, or anal penetration through physical force or threast of physical harm; this includes situations where the victim is incapacitated, such as high, drunk, drugged, unconscious, and unable to consent.

• Three types of rape: Completed forced penetration, attempted forced penetration, and completed alcohol-facilitated or drug-facilitated penetration.

• Sexual coercion: Sexual penetration (vaginal, oral, or anal) that is unwanted but occurs after the survivor is subjected to nonphysical pressure, such as being worn down by repeatedly asking, demonstrating disappointment if the aggressor is told no, being lied to, given empty promises, threatened to end the relationship, being blackmailed or threatened to spread rumors, or using influence or authority against the survivor to pressure them sexually.

• Unwanted sexual contact: Sexual experiences involving touch but not penetration.[CDC. The National Intimate Partner and Sexual Violence Survey: 2016/2017 Report on Sexual Violence]

Epidemiology

The 2017 White House Task Force to Protect Students from Sexual Assault, led by the Obama Administration, emphasized that a one-size-fits-all approach is not an effective way to combat sexual assault. To reduce the incidence of sexual assault, it is essential to better understand the populations that are disproportionately affected. When larger groups are divided into subgroups and intersectionality is considered, more information is acquired that enables healthcare professionals to focus advocacy efforts on the specific needs of distinct communities. Although young females from lower socioeconomic backgrounds experience sexual assault more frequently than males, it is essential to consider intersectionality when evaluating which subgroups are most at risk and how their intersectional identities intensify their risk profile.[3]

Gender identity: Individuals who identify as cisgender women and transgender individuals face higher rates of sexual assault compared to those identifying as cisgender men. 

Sexual orientation: Gay and lesbian individuals experience higher rates of sexual assault compared to heterosexual men, though lower than heterosexual women. Data indicates that bisexual individuals have the highest risk of sexual assault among all identities studied.[4]

Intersectionality: Transgender Black individuals, including those of various races, gender identities, and sexual orientations, experience the highest rates of sexual assault among all groups. Although Black and transgender individuals face the overall highest risk of sexual assault, data from the United States Department of Justice indicate that Native American individuals remain the most at-risk racial group. In addition to this definitive statistic concerning the Native American population, the risks associated with other marginalized racial groups have fluctuated over time. Some studies suggest that individuals identifying as Black and those selecting Other on censuses face the highest risk, followed by those identifying as White, and those identifying as Latinx, Hispanic, or Asian/Pacific Islanders.[4]

Media and popular culture: Stereotypes surrounding rape exist and are portrayed by the media and popular culture. These stereotypes may involve physically violent assault perpetrated by a stranger. As a result, studies suggest that sexual assaults and rapes that most closely fit this definition are more likely to be reported. However, studies show that the majority of rape assaults do not match this definition.[7]

Intimate partner violence/familiar acquaintances: Most rapes (73%) are committed by romantic partners, acquaintances, friends, or family members.[7] However, this does not imply that most of these rapes are reported to law enforcement or medical providers. The nature of the rape and the intersectional identities of the survivor can significantly influence their personal experience. These factors may affect the willingness of individuals to seek assistance from law enforcement agencies or clinicians. 

The care for a survivor of sexual assault warrants an understanding of their intersectional identity within society and how this may contribute to or hinder their propensity to seek medical care. This awareness emphasizes the importance of recognizing, realizing, and responding appropriately to this public health crisis in a way tailored to the individualized needs of those most disproportionately affected. Clinicians must manage the medical care of sexual assault survivors with both sensitivity and precision, creating a safe environment that enables a detailed history, a comprehensive examination, administration of prophylactic medications, and coordination of appropriate follow-up care.

Limitations

Although the existing data on sexual assault provides valuable insights, it is essential to recognize its limitations. Much of the data is gathered through phone surveys and studies conducted at colleges or educational institutions, which may overlook vulnerable populations. Individuals experiencing homelessness, extreme poverty, or living in the country without documentation are often underrepresented or entirely excluded from these datasets. These marginalized groups face significant barriers to reporting and accessing care, including fear of legal repercussions, language barriers, and lack of trust in the healthcare and legal systems. Consequently, the true prevalence and impact of sexual violence are likely underestimated, highlighting the need for more inclusive research methods and targeted outreach efforts.

Clinical Significance

The opportunity to provide trauma-informed care and prioritize these patients begins at the initial point of contact. Caring for a patient who has experienced sexual assault or rape is an extremely sensitive situation for the survivor. When clinicians manage this encounter effectively, it can create a significant opportunity for the patient to reclaim their sense of bodily autonomy, ensure they receive a thorough examination that facilitates legal reporting if desired, arrange essential medical care to prevent adverse outcomes, and provide psychosocial support resources. Unfortunately, many individuals who have experienced sexual assault may develop posttraumatic stress disorder, anxiety, and depression as a result of the trauma.[8] These conditions can hinder their ability to seek follow-up care and counseling after the assault. When they present to the emergency department, survivors of sexual assault and rape should be triaged at a minimum of level 3 in a typical 5-tier emergency department triage system. This approach ensures that the patient's concerns are addressed promptly and informs all staff in the department about the highly sensitive medical care expected.[9]

Initial patient care objectives for hospital staff are as follows:

• Obtain the minimum necessary information to understand the nature of the assault.
• Assess the patient's medical stability.
• Determine whether it is appropriate to involve a Sexual Assault Response Team (SART) if available.
• Use structured interviews among clinicians to minimize repeated questioning, thus avoiding undue distress for the patient.
• Avoid asking the patient to undress or have any physical contact other than necessary for triage before deciding if a forensic exam is desired.[10] 

Patient care objectives of the SART include the following:

• Preserve evidence that can be collected should the patient require further medical and legal assistance.
• Involve appropriate team members, including emergency department medical staff, SANEs, patient advocates, law enforcement, and prosecutors.
• Obtain the history and conduct a medical screening examination.
• The SANE generally performs a focused examination with evidence collection if requested and arranges for follow-up medical care and counseling resources.
• The emergency department clinician must help the patient understand that appropriate medical care does not depend on undergoing a forensic examination, and that making a report to law enforcement is not necessary to have a forensic exam.[10] 
• To facilitate the legal report of the assault and obtain the crime evidence collection kit for processing, patient advocates may stay in the room with the patient to provide support during the visit, prioritizing patient safety and assisting with communication among the various team members.[11] 

Obtaining a History

The purpose of the sexual assault interview is to develop an in-depth, detailed, and clear understanding of how the assault occurred. When the patient is providing the history, all necessary members of the SART must be present to hear the entirety of the history to prevent the patient from needing to repeat the story as much as possible, as this alone can be highly re-traumatizing. 

Key components of obtaining a history include:

• The interviewer should practice empathetic interviewing skills that prioritize patient safety and autonomy.
• This approach can be achieved using patient-centered language and the patient's own words to describe the event while avoiding terms that suggest judgment, such as claimed, alleged, or supposed.
• Furthermore, asking why questions about a patient's decisions or actions before, during, or after the event might imply blame instead of genuine inquiry.
• These techniques are crucial for fostering trust and ensuring a safe environment. Determining whether sexual assault or rape has occurred is not the clinician's responsibility.
• Nevertheless, a clinician can obtain a detailed history that minimizes re-traumatization while emphasizing collaboration, safety, and patient choice. This approach reflects the essential principles of trauma-informed care that all clinicians can adopt. [SAMHSA. Practical Guide for Implementing a Trauma-Informed Approach]

Questions regarding the sexual assault that should be addressed during the history-taking include the following:

• Pertinent past medical history, vaccinations, last menstrual period, and pregnancy status, if applicable 
• Date and time of assault, including possible lapse time between the assault and examination 
• Nature of the physical assault 
• Details of the physical assault
  • Sexual acts performed
  • Penetration of genitalia, anus, or oral contact; non-genital acts; use of objects.
  • Ejaculation occurrence and locations (if applicable) 
  • Use of contraception or lubricant
  • Use of coercion, threats, and weapons

• Detection for alcohol-facilitated or drug-facilitated sexual assault [International Association of Forensic Nurses. Sample Policies and Procedures]
• Other injuries sustained, including physical assault, violent restraint, asphyxiation, head trauma, and loss of consciousness
• Activities after the assault, including hygiene practices, urination or defecation, removal or insertion of pads or tampons, and eating or drinking 

Once a detailed history has been obtained, the medical evaluation can begin. If the patient is pursuing legal action or reporting to law enforcement, a forensic medical examination should be conducted. Please see StatPearls' companion resource, "Sexual Assault History and Physical," for more information.

Record Keeping and Documentation

Understanding that the hospital and medical forensic records are kept separate is essential. This standard means the clinician performing the physical examination is responsible for thorough documentation of the examination that is independent of the sexual assault evidence collection kit, which has its own prompted guide to follow. Despite these 2 examinations potentially overlapping, each is distinct in its purpose and utility. In the sexual assault forensic examination, the examiner assesses any physical injuries that the patient may have sustained during the assault, making a thoughtful trauma-informed approach vital to preventing re-traumatization.

The clinician should identify emergent medical concerns and rule out any life-threatening conditions, injuries, or psychiatric emergencies upon first assessment while deliberately aiming to avoid any re-traumatization, including triggering a patient's physical and emotional trauma responses. While conducting the physical examination, clinicians can affirm patient autonomy by asking for consent before beginning and explaining what each specific portion of the exam will entail. During the sexual assault forensic examination, oral or rectal medications should generally be avoided unless necessary for stabilizing the patient medically.

Examination Kit Preservation

Once the patient is deemed medically stable, multiple methods must be used to conduct the exam to preserve forensic evidence. A healthcare provider should wear non-powdered gloves whenever physical contact is made with the patient. Insertion of a Foley catheter should be avoided. The patient should be instructed not to change clothes, urinate, defecate, eat, drink, or smoke. If clothing must be removed, it should be done tactfully to avoid creating or compromising preexisting tears or stains. Please see StatPearls' companion resource, "Sexual Assault Evidence Collection and Documentation," for more information.

A sexual assault evidence collection kit should be readily available at the hospital; however, each kit is different depending on the local jurisdiction and comes with specific instructions and directions regarding sample collection. Although the kits are typically very detailed and specific, the order in which each sample is collected and how it is collected and preserved is meaningful. In certain circumstances, adjustments can be made to meet the patient's emotional needs, cooperation, and preparedness for sample collection. Should the patient defer particular steps or collections, this should be documented with a reason. Once all specimens are collected and the examination is complete, the kit is sealed and kept with the examiner until passed on to law enforcement or the next proper staff member to maintain a strict chain of command.

Contraception Education

Pregnancy prevention is another aspect of prophylactic counseling that should be addressed. Emergency contraception with ulipristal acetate or levonorgestrel emergency contraception pills should be taken as soon as possible or within 5 days of the unprotected sexual assault. Ulipristal acetate and levonorgestrel have been shown to have similar efficacy if taken within 3 days after sexual assault. However, ulipristal acetate is slightly more effective than levonorgestrel if taken after the 3-day (72-hour) period up to day 5. Both medications significantly lose efficacy after day 4.[12] Adverse effects of these medications may include nausea and vomiting, and antiemetic medicines can be offered.

After day 4, a copper intrauterine device may be considered for emergency contraception.[13] When inserted within 5 days (120 hours), it is 99% effective in preventing pregnancy.[14] However, copper intrauterine devices are not readily available in all settings and are typically not performed in the emergency department. Clinicians can arrange for immediate follow-up with an obstetrician or gynecologist with access to a copper intrauterine device if this is a reliable and desired option for the patient. However, it should be discussed that physical intrauterine device insertion may be re-traumatizing to some patients.

Patients may consider a pregnancy test 14 days after the sexual assault. Body weight has been shown to impact the effectiveness of oral emergency contraception. Levonorgestrel emergency contraception may be less effective in women with a body mass index (BMI) >25, contrary to the efficacy of a copper intrauterine device, which is unaffected by a patient's BMI.[15] 

Infection Risk Management

For patients with abrasions, lacerations, or other high-risk wounds resulting from the assault, tetanus immunization status should be assessed. If there is a superficial skin abrasion and the immunization status is unknown or has been longer than 10 years since the last dose, a tetanus vaccination should be administered. A tetanus vaccination should be administered if a high-risk wound or laceration is present and the immunization status is more than 5 years ago. Administration of 250 units of tetanus immunoglobulin intramuscularly should be considered if the patient did not receive primary childhood immunization against tetanus or has not been immunized. The tetanus immunoglobulin must be given at a different site from the tetanus vaccination site. 

As previously mentioned, follow-up care after sexual assault is often inadequate. This fact underscores the importance of the initial post-assault visit, which is crucial for addressing all medical needs and initiating appropriate prophylactic measures. The harmful sequelae as a result of sexual assault and rape include STIs, pregnancy, blood-borne pathogen acquisition, and environmental injury. STI testing should be determined on an individual basis. Approximately 15% of those experiencing a sexual assault contract an STI.[16] Testing for chlamydia, gonorrhoea, trichomoniasis, HIV, hepatitis B, and syphilis is recommended.[16] Repeat testing is advised at 6 weeks, 3 months, and 6 months.[17][18][19] Empirical treatment should be automatically provided for appropriate sexual assault cases. These STI treatments include those for chlamydia, trichomoniasis, and gonorrhoea. For blood-borne or contact pathogens, such as Hepatitis B, HIV, and human papillomavirus (HPV), more case-by-case risk versus benefit considerations should guide decision-making (see Table. Recommended Prophylaxis for Sexual Assault Survivors). HPV vaccination is recommended for unvaccinated individuals. Please see StatPearls' companion resource, "Sexual Assault Infectious Disease Prophylaxis," for more information.

Table 1. Recommended Prophylaxis for Sexual Assault Survivors

Abbreviations: IM, intramuscular; PO, per os.

Substance Use Considerations

Although gamma-hydroxybutyrate and rohypnol have historically been associated with drug-facilitated rape, they are not the sole substances encountered. Research indicates that more commonly available substances, such as alcohol and marijuana, may also be used. Patients presenting for evaluation after sexual assault or rape may have voluntarily used alcohol or recreational substances before the event occurred. Substance use has historically been viewed as a means to undermine survivor credibility or the validity of reports. An individual's choice to consume alcohol or recreational substances does not determine whether or not a sexual crime occurred, and it is not within the scope of practice of the clinician to make determinations of the role substance use played during the event. Therefore, urine drug screens or ethanol levels are not recommended for routine testing.

If the patient expresses concern that they were unknowingly given a substance or ethanol without their consent, they may request testing to evaluate for drug- or alcohol-facilitated rape or assault. Nevertheless, clinicians should recognize that standard hospital urine toxicology screens based on immunoassays are relatively insensitive, fail to detect many agents used in such assaults, and lack meaningful specificity. Therefore, a forensic urine toxicology screen, often available to law enforcement agencies and based on gas chromatography or mass spectrometry methods, provides much more valuable data, as immunoassays are believed to drastically underestimate the prevalence of drug-facilitated sexual assault.[20] The clinician should obtain explicit informed consent before collecting urine or blood samples for testing. If the patient consents, the sample should be obtained promptly. Opinions on disclosing ethanol or drug screens for survivors are widely debated, as this information could be used to undermine their case in court or even to question their character.

Other Issues

Discharge and Follow-Up Services

Ensuring appropriate discharge planning and follow-up services is essential for the ongoing care and recovery of sexual assault survivors. Once the entirety of the evaluation after a sexual assault has occurred, it is imperative to prepare a thorough summary of what happened during the visit, a safe discharge plan, and a follow-up plan. A well-coordinated discharge plan addresses the patient's immediate safety, emotional well-being, and access to continued support. Providing clear instructions, referrals to mental health services, and information on available community resources can significantly enhance long-term outcomes and reduce the risk of patients being lost to follow-up.

A detailed summary of the visit should be prepared, outlining the following steps—evidence collected, tests performed or deferred, medications received, medications prescribed, medications deferred, information on how to take prescribed medications, follow-up appointments that need to be scheduled or are already planned, and any further specialty referrals, if applicable. The patient should have a follow-up appointment scheduled approximately 2 to 4 weeks after the assault to ensure proper management of STIs, HIV testing, and Hep B management, if needed. If the patient does not have a primary care provider, one should be recommended. As a last resort, a return visit to the emergency room may also be an option.

A safe discharge plan must be established, which involves inquiring about the patient's food and housing situation, support network, and sense of physical safety. Additional planning is necessary if the patient is worried about losing any of these crucial pillars of support and survival after discharge. Discharge paperwork may include information about local advocacy programs, homeless shelters, facilities that provide food to those facing food insecurity, and support hotlines for survivors of sexual assault. Clinicians should also consider a patient's ability to arrange follow-up appointments and transportation, as many patients may not have access to a cell phone, reliable transportation, or the financial means for travel costs.

Providing clear instructions, referrals to mental health services, and information on available community resources can significantly enhance long-term outcomes and reduce the risk of patients being lost to follow-up. Patients who have recently experienced sexual assault should be screened for psychological safety, including suicidality and self-harm risk, with shared decision-making guiding the discharge plan. If a patient is actively suicidal or emotionally unstable following the assault, discharging them from the emergency department may be unsafe. In such cases, additional treatment, observation, consultation, or hospitalization may be warranted. For patients lacking a support system, involving patient advocates or members of the SART can enhance communication and provide continued support after discharge. Connecting patients with a counselor or psychologist after the assault can initiate mental health counseling and promote long-term emotional recovery. Referrals to a psychiatrist may also be appropriate for screening and managing anxiety, depression, or posttraumatic stress disorder, as these are common consequences of sexual assault and may require pharmacological intervention.

Although addressing survivors' immediate medical and emotional needs is the priority, it is essential to inform them that many states offer programs to assist with medical and legal expenses, including financial compensation. Several national resources can help patients access local survivor services and practical support (see Image. National Resources for Sexual Assault Survivors).

Table 2. National Resources for Sexual Assault Survivors

Enhancing Healthcare Team Outcomes

Caring for patients who have experienced sexual assault requires a multidisciplinary approach due to the complexity of their medical, emotional, and forensic needs. Clinicians, social workers, and advanced practice providers play vital roles. Pre-hospital personnel, such as emergency medical technicians and paramedics, are essential in identifying assault victims and preserving clothing and other evidence that may be collected during a forensic exam, should the patient choose to undergo one. In the emergency department, nurses and nursing assistants are often the first point of contact, making them instrumental in recognizing signs of assault, particularly in patients who did not arrive via emergency services. Pharmacists contribute by selecting appropriate medications for postexposure prophylaxis, considering drug allergies and potential interactions with the patient's existing medications. Social workers provide critical support during healthcare interactions and help connect patients with local resources, ensuring access to ongoing assistance and advocacy.