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Sexual violence is a major public health problem in the U.S. with 1 in 15 adults forced to have sex during their lifetime.1 These rates are highest in women, as evidenced by a recent population-based survey reporting that over one fourth of women were raped during their lifetime.2 Although less commonly victimized, males account for 4% to 12% of reported sexual assaults,3,4 and an even higher rate of sexual maltreatment is seen among male veterans.5 Emergency physicians treat 150,000 patients with sexual assault–related visits each year.6 However, fewer than half of sexual assault survivors actually report the assault to police or seek medical care.7 Although there has been a 60% increase in the incidence of sexual assault survivors seeking emergency care over the past 20 years, this is primarily due to an increase in the number of women presenting to the ED after rape by a known assailant.8

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Not all individuals who are sexually assaulted sustain an injury. Only about half have a genital injury on physical examination, and about two thirds have some evidence of bruising elsewhere.9 Thus, it is important to remember that lack of an injury does not mean that an assault did not occur. With regard to the characteristics of the assailant, usually a single assailant is involved, and most often the perpetrator is known to the assault survivor. Force is used in the majority of assaults; use of a weapon is less common.4

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The role of the physician in the treatment of patients experiencing sexual assault is to attend to physical injuries, provide medical care and prophylaxis for pregnancy and sexually transmitted infections, and support the patient by providing referrals and access to community resources. If the patient consents to a forensic examination, this should be done in corroboration with the police jurisdiction in which the attack occurred.

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History

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Patients should be asked about any relevant past medical problems as well as specifics of the assault to guide the ED management. The purpose of the history is twofold: first, to obtain information regarding injuries that need to be evaluated; and second, to obtain information that will help guide the evidentiary examination. A professional, caring attitude should be conveyed throughout the evaluation, and the history should be obtained in private. When a sexual assault advocate or social worker is available, it may be helpful to have that individual in the room during the history taking so that the patient does not have to repeat information. Details to gather about the assault and medical history are listed in Tables 291-1 and 291-2. Most authorities caution that the chances of finding forensic evidence >72 hours after the assault are slim, and therefore a forensic examination should not be performed if >72 hours have elapsed since the assault. If there is high suspicion of drug-facilitated rape, a urine sample can be sent to ...

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