Each year in the United States, between 300,000 and 700,000 adult women are estimated to experience sexual assault, with 40,000 of such victims typically seeking treatment in an emergency department (ED).1 In a survey of hospital EDs published in 2008, only 9.6% of the 117 responding hospitals provided to presenting victims of sexual assault all of the following elements of comprehensive medical care management2:
• Acute medical care
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History and physical examination
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Acute and long-term rape crisis counseling
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Prophylactic and therapeutic management for HIV or other sexually transmitted infection (STI)
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Provision of emergency contraception, with appropriate counseling.2
Specific data from a similar survey included these findings: appropriate, CDC-recommended prophylaxis against STI prescribed in only 6.7% of cases, HIV serology testing in only 13%, and information about follow-up care given to only 31% of patients. Nearly 80% of sexual assault victims treated in the responding hospital EDs received less than optimal care.3,4
In the ED, where victims of sexual assault are most likely to be evaluated, the responsibilities involved in managing the department may hamper emergency physicians’ ability to provide the detailed, time-consuming, one-on-one care such patients require; often, this care is entrusted to an NP or an RN.1 Clinicians in this setting, as well as those who practice in student health, primary care, and women’s health, must be competent in assessing and treating the injuries assaulted patients have sustained, providing STI prophylaxis and pregnancy prevention, collecting forensic evidence in order to facilitate prosecution of the perpetrator, and providing appropriate referrals to promote physical and emotional recovery through counseling and other follow-up care—in short, meeting these patients’ medical, legal, and psychosocial needs.5,6 (See “Specialized Training, a Team Response.”5-7)
DEFINITIONS: RAPE AND SEXUAL ASSAULT
The definition of rape varies from state to state, but three criteria are typically present:
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Sexual penetration of the victim’s vagina, mouth, or rectum
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Absence of consent from the victim
• The use or threat of force.8
Sexual assault is a less restrictive term, referring to the sexual contact of one person with another without appropriate consent. Specified manifestations vary state by state but typically include child sexual assault, incest, marital rape, and other forced sexual acts.7
“Julie,” 18, presents to the ED, accompanied by a female friend, after being sexually assaulted by a male student from the college Julie attends. Earlier that evening, Julie was drinking alcohol at a party in the suspect’s apartment. While everyone else was dancing, he invited Julie to his room. She admits that she was willing to “fool around” with him, but when he asked to have intercourse, she said “no.” The suspect insisted that she “wanted it” and proceeded to engage in unprotected intercourse with her. Julie is distressed because she was a virgin until the encounter and had not been using any form of birth control.
On presentation of a victim of sexual assault, local law enforcement and an advocate from the local rape crisis center should be promptly notified; however, the patient’s permission must be obtained before the police department is contacted. A victim may not want to report a sexual assault to the police for a number of reasons, including:
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A belief that the police are limited in their ability to intervene effectively
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A perception that victims of sexual assault are often considered at fault
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Fear that the assailant may assault the victim again
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Misplaced feelings of fear and shame.5
The NP or PA who performs the initial examination should make every effort to interview the patient while both law enforcement and the advocate are present so that the victim is not required to describe and relive the traumatic situation repeatedly. The advocate is present to support the victim throughout the ED or office visit and evidence collection process; and to provide referrals for follow-up care.
The clinician must strive to remain objective during the evaluation and evidence collection process. For example, the detection of another person’s DNA on the body of the patient is not proof, in and of itself, of that person’s guilt, but only the presence of his or her DNA.9
HISTORY AND PHYSICAL
A thorough medical history and assessment should always be completed, either before or after the forensic examination, depending on the patient’s condition.
Evidence collection is begun by obtaining consent and interviewing the patient. The patient’s account of the assault will guide the practitioner to specific areas of the body where evidence may be found (for example, the case patient said the suspect had kissed her neck, which was swabbed to corroborate her story). Whatever the patient’s age, the presence of a family member or friend is not recommended during the interview, as this could cause the victim to withhold information, and any emotional reaction may be a distraction for the patient. Additionally, having a family member or friend present during the interview process puts that individual at risk for subpoena and court appearance.7