Rape, Sexual Assault, and Sexual Violence

Introduction and definitions

Rape, sexual assault, and sexual violence are prevalent globally, affect all demographics, and have varying definitions. Sexual violence is an umbrella term encompassing all violent sexual acts, including rape and sexual assault.

Some countries define rape very narrowly, for example, the United States at a federal level defines rape as “the penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim” (1). In these contexts, the label “sexual assault” or “sexual violence” would be used for any other non-consensual sexual contact.

Internationally, however, rape is defined as any sexual act performed intentionally on another person without their freely given consent (2).

Epidemiology

Rape and sexual assault are underreported, due to various reasons including fear of retaliation and escalation, legal consequences, desire for confidentiality and privacy, low expectations for positive resolution, and other concerns (3). Numbers reported herein likely underestimate the true prevalence but highlight the significant reach of this deleterious phenomenon.

It is estimated that at least one in three women, one in three nonbinary individuals, and one in four men will experience rape or sexual assault in their lifetime, with rates estimated to be significantly higher (40-75%-plus) in the lesbian, gay, bisexual, transgender, queer, et al. community (4-9).

The prevalence of rape and sexual assault may be increased in individuals experiencing certain social health factors, including but not limited to unstable housing, mental health challenges, and substance use. Additionally, children, elders, individuals with disabilities, individuals with vulnerable social or legal standing, individuals with limited local language proficiency, and individuals from persecuted ethnic or racial backgrounds may also be at increased risk.

Overall, sexual assault disproportionally affects individuals with intersecting marginalized identities, which is further compounded by increased barriers to care, reporting, and justice (4-10).

Key Terms

Please note that this article focuses on medical knowledge, with incidental reference to legal terms. Legal definitions may vary among international jurisdictions and this is not a legal guidance document.

Sexual Assault Forensic Examination (SAFE), the objective formal process of evaluating an individual who has reported rape or sexual assault, which includes history, physical exam, evidence collection, and optional intervention and post-exposure prophylaxis.

Sexual Assault Nurse Examiner (SANE), a certified nurse who conducts a Sexual Assault Forensic Examination.

Wartime/Conflict-Related Sexual Violence: “All sexual violence that is directly or indirectly associated with a conflict, including sexual violence linked to a climate of impunity for perpetrators: (a) rape, (b) sexual slavery, (c) forced prostitution, (d) forced pregnancy, (e) forced sterilization/abortion, (f) sexual mutilation, and (g) sexual torture violations perpetrated by armed actors (specifically, state militaries, rebel groups, and pro-government militias) during periods of conflict or immediately post conflict” (11-13).

Human trafficking: The use of force, fraud, or coercion to elicit any type of labor and/or commercial sex act (14). Trafficking is prevalent throughout the world in many different forms: from individual dyads (trafficker and trafficked person) to complex, multi-level organizations, and from locally focused to international and intercontinental transport. By definition, trafficking involves impairment or absence of consent and therefore overlaps significantly with rape and sexual assault. Individuals reporting rape and sexual assault should be evaluated for concern for human trafficking.

Trauma-informed care

Any encounter with an individual reporting rape or sexual assault should utilize a trauma-informed approach, throughout the interaction, in any setting. Trauma-informed care is an emerging approach to interacting with others that:

• recognizes their history of trauma (specific or universal)
• provides physical and emotional safety
• avoids retraumatization or further trauma
• optimizes the outcome of the encounter
• improves their trajectory of healing (15, 16)

While every individual’s needs are unique, patients experiencing sexual violence have described certain common priorities that are valued during the response phase, including “being heard and believed by all…; control over support, service options, and the recovery/healing journey; accessing supportive counseling…; having the right support…; and [having their] needs responded to in a timely manner” (17).

Certain key elements may facilitate a trauma-informed assessment to a rape or sexual assault assessment:

PRIVACY: Optimize privacy to whatever degree possible

Provide a private space for conducting the history and physical exam, without the presence of others. Patients may be provided a dedicated, trained advocate/companion. For patient safety reasons, ensure that anyone accompanying the patient leaves the area, in order for the patient to answer autonomously, in case their companion is the abuser. In less-resourced settings, it is recommended to use any available privacy-focused modifications, for example, quieter discussion away from others, sheets or drapes to cover when conducting genital exams, or other available modifications (18).

LISTENING: Listen attentively and convey respect for the patient’s statements. As a reminder, it is not the role of the clinician to evaluate the veracity or strength of the legal claim, so there is no harm, and potential benefit, in conveying belief and support (19).

UNDERSTANDING: Be aware of certain basic tenets of rape and sexual assault care: there is no one way a patient will present, physically or emotionally; during trauma, expected reactions may include fight, flight, freeze, or fawn; and a patient’s cultural or psychosocial identity may inform their responses, their needs, and their interpretation of events. Trauma response behaviors vary widely and may include combative resistance, crying, submission, dissociative silence, or even appearing unexpectedly “normal” and unaffected. None of these should increase or decrease the perceived validity or severity of the patient’s trauma (20).

INFORMATION: Provide the patient with adequate information about the experience. This includes stating the roles of everyone in the room, explaining the purpose of history questions, explaining each examination step and its purpose, and discussing the overall process, next steps, and what to expect.

PATIENT AUTONOMY: Center the patient’s autonomy throughout the process. A key priority reported by survivors is “control over support, service options and ultimately the recovery/healing journey (choice and empowerment)” (17). In addition to the above measures, patient’s autonomy may be prioritized by allowing the patient to determine the pace and what steps are included in the history, physical exam, management, and follow-up steps.

Documentation and legal considerations

In addition to trauma-informed care and careful assessment, treatment, prophylaxis, and resources, one of the most valuable ways to help a survivor of rape and sexual assault is documentation.

Purpose: Medical documentation is evidence in rape and sexual assault cases. In many settings, medical documentation of patient’s physical examination findings is considered the gold standard in objective, factual data (21).

Furthermore, medical documentation of patient’s report of the event history and concerns may also constitute valid evidence (21). This means that the statements a patient makes regarding the assault history may be used in legal proceedings. This has complex consequences – it may benefit the patient by supporting their case, however there may be unintended negative consequences if there are discrepancies in details between reports (which may be a common occurrence related to how trauma influences recall) (22).

Wartime/Disaster/Austere Settings: Even in settings where medical records may not be preserved or cases not promptly prosecuted, any attempt at documentation may possibly benefit the patient. Documentation of rape, sexual assault, and other torture supports patients’ legal pursuit of asylum.

One of the biggest challenges in asylum cases is that patients are unable to collect documentation in the acute phase of torture for obvious reasons. If available, consider either providing patient (safely) with printed documentation and/or utilizing a secure, internationally-accessible database to store documentation that may be accessed later.

Best Practices:

• All medical documentation should adhere to the highest standards of fact-focused objectivity.
• Patients’ statements should be captured verbatim. This may be a divergence from typical recommendations regarding implicit bias in medical documentation.
• Avoid the use of editorializing, undermining, or commenting on the perceived veracity of patients’ reports. Terms like “alleged,” “claims,” and other doubt-conferring vocabulary should be avoided, as with other encounters. Terms like “patient reports,” “patient states,” and other strict fact-based assessment should be utilized.
• Avoid using the term “victim” when referring to the patient. “Victim” is often a legal term and conveys bias which may undermine the use of pertinent history, data, and evidence in judiciary proceedings. The term “patient” is an appropriate substitute in a medical environment.
• History-taking should be narrowly focused toward guiding the medical assessment, and avoid broader inquiry into the legal details. This mitigates against the aforementioned risks of patient report discrepancy.
• Physical exam findings should be comprehensive and should be documented with precision, utilizing ruler measurements and photography (with patient consent and security/privacy measures). 
• Each patient comment or explanation regarding a specific injury or finding should be documented. For example, where the physical exam may document a raised, erythematous, 3cm x 11cm lesion laterally distributed across the lower back, the history may contain a comment that the patient was struck with a leather belt approximately 3 days prior to presentation.
• Assessment of perceived causality may be classified into the following categories:

Diagnostic of assault/abuse: The highest threshold. This is limited to injuries whose appearance could not have been caused in any other way than the action the patient reports. An example may include: a cervical laceration surrounded by bluish powder peri-cervix is diagnostic of abuse, in a case where a patient reported being forcibly penetrated by a pool cue (23).

Highly consistent with assault/abuse: Documented injuries could have been caused by the trauma the patient described. An example includes a patient describing forced vaginal penetration who exhibits a gaping genital tear at six-o’clock to the fossa navicularis several days outside of the date of last consensual penetration.

Typical of assault/trauma: This is a finding that is usually encountered with the type of trauma described by the patient, but there are other possible causes. An example is a patient with a history of severe constipation who had a difficult bowel movement the day of a described sodomy assault, yielding a single tear to an anal fold.

Consistent with assault/trauma: A finding that could have been caused by the trauma described, but it is non-specific and there are many other possible causes.  An example is a patient describing digital vaginal penetration with an abrasion to external genitalia when there is a history of an active yeast infection with pruritus.

Not consistent with assault/abuse: A wound could not have been caused by the trauma described. An example is a positive gonorrhea culture with an assault history of vaginal penetration within six hours of examination (2).

Guidance for war/conflict, disaster, and other austere settings

War/Conflict-Related Sexual Violence

Sexual violence is a widely prevalent weapon utilized in war and political conflict. Sexual violence includes “rape, sexual slavery, forced prostitution ([human trafficking], forced pregnancy, forced sterilization/abortion, sexual mutilation, and sexual torture violations perpetrated by armed actors (specifically, state militaries, rebel groups, and pro-government militias) during periods of conflict or immediately post-conflict” (11). Women and young girls are extremely vulnerable to these forms of abuse, although males are not excluded in sexually abusive practices.

Factors influencing sexual abuse in wartime include individual factors, such as power and control, demoralization of the disenfranchised, financial gain, and structural factors, particularly the “breakdown of legal structures, social networks and livelihood options in settings affected by conflict and displacement” (24).

Rape and sexual assault specifically may be weaponized against individuals of any gender, with the collective intent and impact of dehumanization of the populace, emotional or physical disabling of the potential military, or financial gain in human trafficking (25). Child soldiers (defined as a child under the age of 18 who is used by armed military) may be used for sex labor, rape by military personnel, spies, and human weapon carriers (i.e. bombs and grenades), and have a “direct part in the hostilities” (26).

The clinical guidance herein often requires a secure, flexible, modifiable environment which may not exist in wartime, disaster, or other austere settings. Where possible throughout this document, suggestions have been provided for modification of approach in these settings.

Major considerations and goals when dealing with individuals reporting rape or sexual assault in the context of a wartime, disaster, or other austere setting:

1. Trauma Responsiveness: in addition to the psychological trauma associated with sexual violence, individuals in these settings may also be experiencing profound acute and chronic trauma related to the circumstances of the political conflict, disaster, or baseline setting in which they are presenting. Use of a trauma-informed approach is imperative, especially when working with child survivors of conflict and refugees (27).
2. Privacy: any available privacy-oriented modifications (e.g. distance from others, sheets or tarp covers for exam, quiet discussion) may help optimize patient’s mental health and allow history and examination.
3. Documentation and examination in wartime settings are generally conducted for trauma-informed patient care rather than evidentiary analysis. An examination of the patient’s body in a trauma informed approach validates the trauma that the patient has experienced and facilitates equitable medical care and treatment (as able to be afforded in wartime settings). Where possible, documentation may support future asylum applications.

Clinical presentation

Individuals who have experienced rape or sexual assault may present for care in a broad variety of contexts – self-report or bystander concern, alert and oriented or with altered mental status, acute or delayed, in psychological distress or composed demeanor, with primary concerns or via incidental disclosure (28).

Clinicians must release any preconceived notions of what they expect of a typical rape/assault survivor presentation to ensure that all individuals receive the thorough care that they require. The clinician’s role is not to evaluate the veracity or magnitude of the legal claim; the clinician’s role is to care, address concerns, provide treatment and prophylaxis, and collect and document forensic evidentiary findings when appropriate (29).

1. Altered Mental Status or Unconscious Patients
   
   Individuals who have experienced rape or sexual assault may present unconscious or with altered mental status, with or without history or signs suggestive of rape or sexual assault, e.g. bystander/medic report, torn or missing clothing, and/or visible trauma or bleeding around the mouth, genitals, breasts, or buttocks. A medical evaluation may be performed on an unconscious patient or a patient who is clinically sober as appropriate; however, a practitioner must adhere to legal protocols prior to implementing a forensic evidentiary examination on such patients. Options may include delay of forensic evidentiary exam until such time as a patient becomes alert and responsive in order to give consent; or collection of evidence and maintenance as a “blind report” as per jurisdictional protocols and stand operating procedures (28, 30-32).
   
2. Conscious and Oriented Patients – Acute/Recent Incident
   
   Individuals who have experienced rape or sexual assault may present in a conscious and oriented state and you may be alerted to their history by self-report of acute/recent event during initial arrival, delayed self-report of prior event on arrival, medic/chaperone report on arrival, or later disclosure during evaluation. There may also be no report and the concern for rape or sexual assault may arise from signs encountered during the physical exam.
   
   Patients who self-report may present with the goal of receiving a sexual assault forensic examination (SAFE) with or without police involvement, receiving evaluation and prophylaxis against pregnancy and sexually transmitted infection (STI), receiving medical evaluation and care, finding a safe harbor from further danger, and/or with non-specific concerns and uncertainty in an acute stress state (28, 32).
   
3. Conscious and Oriented Patients – Delayed Disclosure or Incidental Discovery
   
   Due to the complex nature of trauma, as well as potential constraints on access to care, individuals who have experienced rape or sexual assault may disclose their assault at a time significantly beyond the time of the incident(s). Although the nature of evaluation and management may change, there are still many elements in this type of clinical encounter that are crucial for the patient’s health and overall outcomes (31). Pediatric patients may be more likely to have incidental discovery after presenting for other concerns, including enuresis, encopresis, nonspecific genital or other pain, and/or behavioral concerns (33).

Evaluation

1. Trauma-Informed Approach (Link to TIC section)
2. Basic Initial Assessment, Forensic Assessment, & Evidence Preservation:

For patients presenting with an acute report of rape and sexual assault, consideration for evidence collection and forensic evaluation should be part of the initial assessment. While numeric cutoffs may be specified locally for what is considered acute versus delayed presentation (e.g. 72-120 hours post-event), this is a subjective spectrum. There is value in considering what forensic components may be identified during examination regardless of the time of presentation. Where available, certified or trained SAFE examiners should be engaged prior to any patient evaluation – with the exception of patients requiring acute resuscitation. In the absence of trained evaluators, any provider may conduct an examination with respect to certain forensic principles and guidelines.

Wartime, Disaster, and Austere Settings: evidence collection may not be feasible due to limited availability to preserve or process specimens. Thorough assessment and documentation are still crucial for the patient’s physical health, mental wellness, and the future ability to seek follow-up care, legal recourse, and/or asylum.

History-taking for rape and sexual assault includes the traditional information collected for any other medical encounter: basic event description, symptoms and concerns, and patient’s medical history. The use of a trauma-informed approach is imperative. History-taking should be considered as information for directing the forensic examination. The assessment should be medically oriented and not a legal interview. Focusing on the key elements of the medical history, event, and current symptoms has multiple purposes:

• it limits the patients’ retraumatization by recounting the trauma to multiple individuals unnecessarily
• it preserves the integrity of the patient’s legal history reporting of the event for the law enforcement / public safety report. It is known that acute reports of sexual assault and other trauma may vary as the patients’ memory can be compromised during the traumatic stress post-event phase (22, 34, 35). Recording a history that may conflict slightly with the subsequent legal report could put the patient’s legal case at risk (31).

Considerations for Pediatric/Minor Interviews: The pediatric interview is often more significant than the exam, which may have more subtle, occult, or nondiagnostic findings (33). Interviewing the pediatric patient should be limited in the clinical encounter, with a detailed interview scheduled with a specially trained forensic interviewer. Many communities have forensic interviewers who work within structured Children’s Advocacy Centers (CACs). Interviews conducted by law enforcement and untrained medical staff may be called into question during judicial proceeding and questioning that may be deemed “leading.”

At the time of trial, significant time may have passed, children are older, and their memories may have undue influence from accounts that they have heard from parents or other adults. The forensic interview by specially qualified persons are often video and audio recorded in order to create a permanent record of the child’s history of assault or abuse (36).

Considerations for LGBTQIA+ Interviews:

Individuals in the LGBTQIA+ community experience significant discrimination globally, in many jurisdictions facing legal repercussions for their existence. Care should be taken to respect the local context when documenting information disclosed about their sexual orientation, activity, and/or gender identity. Individuals from this community are at increased risk of experiencing rape and sexual assault, and due to discrimination, may have significant caution, fear, and hesitance to disclose sexual violence that they have experienced (37). Interviewers should use trauma-informed care and situational humility, avoiding making assumptions about anatomy, sexual activity, orientation, and gender identity.

Trafficking assessment:

Human trafficking is the elicitation of labor and/or sex work using force, fraud, or coercion. A history or patient report of rape or sexual assault may raise concern for human trafficking. Individuals of any age should be interviewed for signs and concerns for trafficking when reporting rape or sexual assault. Numerous screening tools exist, including the Comprehensive Human Trafficking Assessment and the Short Screen for Child Sex Trafficking (38, 39).

Depending on the evaluation context, human trafficking assessment may be deferred to social work or a SAFE examiner. Clinicians may consider using a validated screening tool or informally asking the patient about whether there is anyone who has undue influence over their work, housing, finances, children, decision-making, or in any way coerces them into sexual or other work activities.

PHYSICAL EXAMINATION

Patients who present unconscious or with altered mental status, with either signs or bystander report of rape or assault should receive a comprehensive assessment and acute trauma and medical resuscitation/stabilization per standard-of-care guidelines described elsewhere.

Additionally, all patients who present unconscious or with altered mental status should be evaluated for signs suggestive of rape or sexual assault, even in the absence of bystander report.

These signs of rape or sexual assault may include:

• Torn, missing, or improperly worn clothing (e.g. open zippers, buttons mispaired or unbuttoned)
• Perioral, intraoral, genital and/or anal trauma – lacerations, bleeding, swelling, bruising

In many jurisdictions, similar to the implied consent to treat an unstable patient medically, there is implied consent to sexual assault forensic examinations. This should be confirmed at the local jurisdictional level before proceeding.

EVIDENCE CONSIDERATIONS

All of the following may contain forensic evidence. Care should be taken to collect if appropriate or to preserve while awaiting a trained forensic examiner. The following collection guidelines were written with respect to SAFE exam practices, but this document does not constitute an official training on the SAFE exam.

PLEASE NOTE: if there is any concern for life-threatening conditions, the patient’s acute resuscitation takes precedence over evidence collection (e.g. need for exposure, need for oral and genital examination or intervention). (Link to exam below)

GENERAL PRINCIPLES OF FORENSIC EVIDENCE COLLECTION:

If a forensic examiner is available to conduct the exam, the role of the clinician should prioritize emergency stabilization and evidence preservation, while collaborating with the forensic examiner on sequence of next steps.

The “Preserve” options should be utilized if awaiting a trained SAFE examiner; the “Collect” options should be utilized if the clinician will be the lead on collecting and submitting forensic evidence.

Clothing and personal items

PRESERVE: Use judgment to safely balance the need for exposure (e.g. full exposure emergently needed in severe trauma) with the need to collect evidence carefully (e.g. if patient stable, conscious, with clear history).

COLLECT: Have patient stand over a brown sheet of paper and carefully disrobe so that any foreign material falls straight down, collect all personal items and garments into a brown paper bag

Foreign material on body, e.g. blood, semen, saliva, other material

PRESERVE: Use trauma-informed care to explain to patient that it’s best to conduct forensic examination first and delay any cleanup process until the forensic exam occurs.

COLLECT: Use swabs to collect evidence, individually labeled and sealed. Swab any areas with visible residue, areas described by patient as involved in the assault, and include oral, genital, and anal regions as described below, if patient is unsure or doesn’t recall all incident details. Collect swabbings from under fingernails. Collect combings and – depending on local crime lab protocols – plucked samples of hair from head and genital regions. Toluidine blue dye (TBD), a nuclear stain, may be applied sparingly to external genitalia and thoroughly cleaned with KY gel or a 1% acetic acid spray. Dye may adhere to an open/damaged cell nucleus and affords more detailed photography and wound assessment.

Patient’s orifices

PRESERVE: Maintain NPO status (avoiding water and oral medications) and do not encourage/require urination or early oral or genital/pelvic exam while awaiting forensic examination.

COLLECT: Collect patient’s first urine in a labeled and sealed specimen container – do not send first urine to laboratory. Initial oral and genital/pelvic/anal examination should be conducted in accordance with forensic guidelines below. Use swabs to collect evidence, individually labeled and sealed.

Overall Swabs:

When/where to collect evidence via individual swabs, labeled and sealed:

• any location where visible foreign material is present
• any location reported by patient as involved in the assault
• for patients with altered mental status or uncertain memory of events, include intraoral, genital, anal, and any other area with visible trauma

Injury Assessment/Documentation:

Alternate Light Source: Bruise detection may be challenging, with variation due to skin pigmentation, mechanism of injury, time lapse and other factors (40). Alternate Light Source (ALS) units are instruments that utilize bands of light from 300-600nm wavelength that are filtered into band widths. Evidence may be reflected, absorbed, or fluoresce.

When choosing a wavelength, typically 400-460nm, and donning yellow, orange or red protective eye goggles, wounds that are latent to the naked eye may become visible affording photographic and other documentation.  These may include patterned markings and bruises. Wavelengths of 300-350nm, also known as “Woods lamp” or “black light” may reveal fluorescence of fluids such as semen or saliva, or lubricants which assist the forensic examiner in knowing where to swab during the evidentiary examination (23).

Measurements

A ruler should be used to measure all wounds assessed in the forensic examination. The rule must be held on an even plane with the wound being measured to prevent distortion of the measurement reading. For bite marks and bruises, an American Board of Forensic Odontology (ABFO) ruler may be used. This ruler is a right-angle ruler and accurately measures non-linear wounds (23).

Photography

The introduction of digital photography warrants the practice of “bookending” all forensic photographs to assure that if multiple cases are photographed on a single memory card, there will be no confusion in wound or other photos. The first photograph should be a patient identifier. This may include a patient label, or a white board with pertinent patient information including date, patient name, a police complaint number or holding number and name of the forensic photographer. It is recommended that the second photograph be a patient facial view with the eyes open.

Photographs should be taken using rule of thirds: the first being far enough away from the patient to ascertain where the wound is in relation to the body (e.g. right chest, left upper arm); the next photo is taken 1/3 of the distance closer to the wound; the next photo at a 90 degree angle and close to the wound, and the last photo also at close proximity to the wound with a ruler.

At the end of the photographic evidentiary exam, the forensic photographer should close out the photo series with a picture of the patient identifier (patient label or white board. This assures closure to the series of photos comprising the body of evidence. No photo should be deleted from this series of pictures including blurred images (23).

FOCUSED PHYSICAL EXAM AND REVIEW OF SYMPTOMS

Secondary survey: Information below describes rape and sexual assault focused examination that may be conducted in addition to either a comprehensive secondary trauma assessment and/or a symptom-driven examination. Data suggests that non-genital injuries may be present in 50-70% of sexual assault encounters (41, 42).

Constitutional/Neuro/Mental Status:

Any patient presenting with altered mental status and concomitant concern for rape or sexual assault should be evaluated with a standard altered mental status workup, including evaluation for acute intracranial injury from trauma to the head or neck (strangulation) and evaluation of psychiatric distress as a sequelae of trauma.  

Airway/HEENT: Evaluate airway for patency, stridor, dysphagia, odynophagia, and/or voice changes reported by patient. Examine neck for bruising or swelling consistent with strangulation. Ligature marks, finger/handprints, or scratch marks may be present. Examine head, neck, and eyes for trauma, including petechiae, scleral, and subconjunctival hemorrhage. Note the presence or absence of all three frenula.  Utilize ALS for bruising assessment.

Mouth

Conduct perioral and intraoral examination for lacerations, bruising, swelling, petechiae, or other injuries. Utilize ALS and TBD for further injury assessment. Collect evidence as described previously, via saliva/swab. Collect swabs for STI testing.

Pelvic, Genital, and Anal Examination

People of all gender identities and biological sexes are at risk of sexual assault. Understand that one’s gender identity does not necessarily determine the anatomy that one may have. Below are guidelines for any anatomy that examiners may encounter. As with any patient, it may be informative to collect any surgical history to understand the patient’s baseline.

All: Examine external genital and anal regions for lacerations, bruising, swelling, or petechiae. Utilize ALS and TBD for further injury assessment. Collect evidence as described previously, via saliva/swab. Collect swabs for STI testing.

Examination of sex organs should include (where present):

• perineum
• peri-urethral tissue and urethral meatus
• labia majora, labia minora, clitoris, hymen, fossa navicularis, posterior fourchette
• foreskin, shaft, scrotum, perineum, glans, testes (32)

Baseline anatomy and non-concerning/nonspecific findings differ among prepubertal, peripubertal, and postpubertal patients. Care should be taken to distinguish this in exam documentation.

LABS

Altered mental status: Any patient presenting with altered mental status and concomitant concern for rape or sexual assault should be evaluated with a standard altered mental status workup. However, there are certain legal considerations regarding drug-facilitated sexual assault. In certain settings, it may be advisable not to test for drugs that facilitate sexual assault, due to the transient nature of detectability, and risk of undermining the patient’s valid claims (43).

Baseline testing for pregnancy is advised in any patient physiologically capable of being pregnant.

In adults and post-pubertal adolescents, it may be more advisable to empirically treat certain potential conditions without testing, including gonorrhea, chlamydia, trichomonas, and bacterial vaginosis. The benefits of empirical treatment are multifactorial, including avoiding delay awaiting results, eliminating risk of loss to follow-up, and preventing baseline results from being used to discredit or stigmatize the patient in legal proceedings (44). Baseline/antibody testing for syphilis, Hepatitis C (HCV), Hepatitis B (HBV), human immunodeficiency virus (HIV) is advised in adults and post-pubertal adolescents.

Testing in pre-pubertal children should be tailored to the exposure, the assailant status if known, local prevalence patterns, and any other case factors. Positive STI test results in children are diagnostic of sexual assault or rape. Refer to subsection: “Sexually Transmitted Infection (STI) – Empiric Treatment, Post-Exposure Prophylaxis, and Surveillance” in Management for more information.

If HIV prophylaxis will be provided, baseline creatinine and AST/ALT liver testing is indicated.

Condition- and history-directed labs: Patient-specific assessment should be included within standard practice, for example, hemoglobin in the setting of significant bleeding or symptoms of shock.

IMAGING

For trauma report or exam, consider comprehensive/trauma CT and/or FAST ultrasound protocol.

If there is any concern for strangulation, consider CT angiography of carotid and vertebral arteries or CT Head & Neck (less sensitive) (45). Chest X-ray may be considered to assess for signs of pulmonary edema and aspiration pneumonitis (44).

Concern for strangulation may arise from:

• History: patient “choked”, “strangled”, “suffocated”, loss of consciousness/memory
• Symptoms: dysphonia/aphonia, throat swelling, dysphagia/odynophagia, dyspnea, changes, neurologic abnormalities (e.g. incontinence)
• Exam: neck bruising or tenderness, ligature marks, oropharyngeal injury or edema,
  • facial/intraoral/subconjunctival petechiae or hemorrhage, subcutaneous emphysema,
  • neurological exam abnormalities (45).

For patients with existing pregnancy, perform basic fetal ultrasound, tocodynamometry, or other monitoring if indicated based on gestational age.

Management of acute presentation

Guidelines suggest various cutoff times from the acute event to be considered delayed presentation (e.g. 72-120 hours) (18, 46). This may be extended at the clinician or SAFE examiner’s discretion. This cutoff does NOT eliminate the need for or benefit of other management options.

Trauma-Informed Approach:

As with evaluation, management of rape and sexual assault should utilize a trauma-informed approach for all individuals, in any setting. Key elements include:

• optimizing privacy to whatever degree possible
• explaining the purpose of proposed interventions and options
• proceeding at a pace comfortable for the patient
• overall centering the patient’s autonomy and consent for management decisions.

Невідкладна стабілізація

Зґвалтування або сексуальний напад може бути досить жорстоким, щоб викликати фізичні та психоемоційні ушкодження, що вимагатимуть заходів невідкладної медичної реанімації відповідно до стандартної практики, описаної в іншому місці.

Emergency Stabilization:

A rape or sexual assault may be violent enough to induce physical and psychoemotional injury requiring acute trauma and medical resuscitation in accordance with standard practice described elsewhere.

Strangulation:

Patients with concerning imaging findings may require admission for further intervention (including intubation, surgery, or critical/intensive care). Patients with concerning history, symptoms, or physical exam and reassuring or non-diagnostic imaging may benefit from continued hospital observation. Patients being discharged should be provided with detailed guidance on when to return to the emergency department for concerning symptoms, including neurological signs/symptoms, dyspnea, dysphonia, or odynophagia (44, 45).

Sexual Assault Forensic Examination:

As described previously, the clinical pathway for a rape and sexual assault patient may vary significantly based on the availability of a trained SAFE examiner and/or the clinical context regarding whether forensic evidence can or cannot be collected or preserved (e.g. wartime/conflict, disaster, or austere settings). If a SAFE examiner, referral center, or safe evidence chain-of-custody process is promptly available, the following management steps may be briefly delayed to await forensic evidence collection in medically stable patients.

Traumatic Injury:

Management of acute trauma – fractures, bleeding, and other injuries – should proceed according to standard guidelines.

Sexually Transmitted Infection (STI) – Empiric Treatment, Post-Exposure Prophylaxis, and Surveillance

Empiric treatment for several STIs is recommended at the index visit to optimize outcomes and minimize the need for follow-up care. Local contexts should be considered regarding specific treatment availability, local patterns of antibiotic resistance, and local prevalence of infections (i.e. likelihood that assailant was infected), to treat more proactively if indicated.

The below suggestions reference the United States Centers for Disease Control guidelines for post-sexual assault treatment and prophylaxis and other evidence-based guidelines.

Adult/Post-Pubertal Adolescent Patients

Pre-Pubertal Patients

Given low prevalence of STI in pre-pubertal survivors of sexual assault, no comprehensive prophylaxis strategy is recommended. Testing, prophylaxis, and surveillance recommendations should be tailored to the exposure, the assailant status if known, local prevalence patterns, and any other case factors. HPV vaccination is recommended in eligible patients nine years old and above.

Pregnancy prophylaxis:

At the patient’s discretion, and subject to local availability, pregnancy prophylaxis (emergency contraception) should be offered to any patient who may biologically have the capacity to become pregnant. In many jurisdictions, it is legally mandatory to offer emergency contraception after rape or sexual assault.

Recommended options include levonorgestrel (LNG-EC) 0.75 mg x 2 or 150mg given within 120 hours, ulipristal, or copper IUD. Also, combined 100 mcg of ethinyl estradiol and 0.5 mg of levonorgestrel (2 OCPs bid q12h) is a historical, but less effective option. In many countries, mifepristone 600mg may also be available (47, 48). Pain and nausea management: in addition to comprehensive evaluation and management of injuries, patients should be provided appropriate analgesia and antiemetics as needed, using a patient-centered decision on the timing of oral and parenteral medication to avoid evidence contamination yet minimize additional trauma and distress.

Psychological Health and Social Referrals

Where available, all patients should have a consultation with a social work professional to discuss the patient’s safety and social situation. All patients should also be referred for social services and psychological counseling. The psychological sequelae and trauma resulting from rape and sexual assault may be severe, profound, and pervasive. Although patients’ psychological needs may be best served longitudinally by trained mental health professionals, clinicians in the acute encounter may provide value by utilizing a trauma-informed approach and including several elements of reassurance and validation including:

• listening to the patient’s report
• expressing belief in the patient’s report
• validating emotions that the patient may be experiencing, while encouraging the patient away from self-blame
• reassuring the patient that common human responses in acute traumatic encounters may include “freezing” (i.e. tonic immobility), “fawning” (i.e. yielding to the assailant), or the possibly more familiar responses of “fight or flight”, and none of these responses imply consent (49).
• reassuring the patient that their body may have responded physiologically (e.g. arousal, erection, orgasm), but that does not mean that they consented, wanted it, enjoyed it, or were responsible for what happened (50).

Disposition

Stable patients may be transferred to a SAFE center for forensic examination and additional services.

Patients with medical conditions requiring additional care should be managed in accordance with the patient’s status and medical needs, including observation or admission if indicated.

Patients with concerning history, symptoms, or physical exam regarding strangulation and reassuring or non-diagnostic imaging may benefit from continued hospital observation or admission.

Patients with medical instability and/or concerning imaging findings regarding strangulation likely require admission for further intervention (including intubation, surgery, or critical care).

As stated previously, any patient being discharged should be assessed for safety, provided with return precaution guidance, and linked to follow-up testing and psychosocial services.

Complications of rape and sexual assault and implications of delayed presentation

Individuals are at risk of complex sequelae of rape and sexual assault regardless of whether they received acute care at the time of the incident, although many sequelae may be more severe if the individual was unable to seek care immediately.

Pregnancy: Penile-vaginal contact may result in pregnancy in an individual of child-bearing age with female reproductive organs. This may be mitigated by pre-existing contraception (e.g. patient’s intrauterine device, oral medication, or other interventions) or peri-incident/post-exposure prophylaxis but remains a risk. These pregnancies are emotionally and socially complex. Individuals may struggle with decisions around continuation of pregnancy and pursuit of prenatal care (51, 52). Furthermore, the political climate for abortion around the world is widely variable, ranging from freely available elective abortion, abortion only in cases of rape and incest, to fully prohibited abortion (which usually means that unsafe abortions with potentially dangerous practices are the only option available). Furthermore, any pregnancy is physiologically significant and carries a risk of morbidity and mortality for the individual.

Complications of abortion: For individuals who seek abortion for a pregnancy resulting from rape, there are the standard risks of abortion, including hemorrhage, infection and septic abortion, and death.

Infertility: Infertility in individuals with female reproductive organs may result from vaginal and/or cervical scar tissue from physical trauma, or due to sequelae of untreated infection. Infertility in individuals with male reproductive organs may result from physical trauma to the sex organs as well as sequelae of untreated infection (53, 54).

Other complications may be associated with undiagnosed and untreated sexually transmitted infection including Fitz-Hugh-Curtis syndrome; secondary, tertiary, and neurosyphilis; and complications of HIV (55).

Complications from oral penetrative assault include airway edema and delayed asphyxiation, oral abscesses and infection, scar tissue, and sexually transmitted infection (56).

Complications from anal penetrative assault include rectal puncture and hemorrhage, abscesses and infection, scar tissue, and sexually transmitted infection (57).

Other trauma: as rape and sexual assault are often associated with traumatic injury elsewhere on the body, the associated complications of those traumatic injuries remain a risk and are described elsewhere.

Vaginismus (the involuntary contraction of vaginal/pelvic muscles in the setting of attempted vaginal penetration), dyspareunia (pain related to sexual intercourse), and other genitopelvic pain disorders are conditions associated with a history of sexual trauma (58).

Post-traumatic stress syndrome (PTSS/PTSD) and a related condition, rape trauma syndrome, are frequent sequelae of rape and sexual assault. Some studies indicate 50-90%+ prevalence of symptoms of PTSS/PTSD in survivors of sexual assault (59). There is also an increased risk of other behavioral health syndromes, including substance use, major depression, and borderline behaviors (60).

Social and legal consequences: Even in countries where rape is a crime, individuals often experience social consequences including public scrutiny for filing charges or private consequences including ostracization and loss of social support. Individuals in romantic partnerships or marriages who are raped by an individual other than their partner may experience retaliatory violence by their partner (61). Furthermore, in several countries, it is considered a crime to be the victim of rape if one is married; this is perceived as adultery and may be punishable by violent injury (e.g. stoning) or death (62).

Summary

• Rape, sexual assault, and sexual violence are prevalent globally, affect all demographics, and have acute and chronic consequences for the survivors.
• Trauma-informed care is crucial – recognizing the impact of trauma, avoiding retraumatization, ensuring privacy, listening, providing information, and centering the patient’s autonomy.
• Careful, factual documentation may be a valuable way to facilitate the patient’s long-term outcomes.
• Rape, sexual assault, and sexual violence are frequently used as a tool of war and political conflict; individuals experiencing these in a wartime, disaster, or austere settings may need modified approaches to evaluation and management, but there are still significant ways that clinicians can help these patients’ acute and long-term outcomes.
• There is no standard presentation for an individual who has experienced rape or sexual assault; the clinician’s role is to respectfully evaluate the patient’s medical needs and provide treatment and prophylaxis in collaboration with the patient.
• Certain populations are at increased risk of rape and sexual assault, as well as increased trauma during the reporting and healthcare process, including LBGTQIA+ individuals, marginalized racial and ethnic identities, asylum-seekers and refugees, pediatric patients, individuals with disabilities, and individuals with social health challenges; attentive, equitable, collaborative trauma-informed care is advised.
• Evaluation: preserve evidence to conduct or refer to sexual assault forensic exam; thorough physical exam to assess and document genital, anal, and oral injuries; exam and imaging to assess for strangulation and other non-genital injuries; baseline testing for pregnancy, HBV, HCV, HIV, and syphilis.
• Management: prophylaxis for pregnancy, gonorrhea, chlamydia, trichomonas, and HBV; vaccination for HBV, HPV; injury care as indicated; admission to appropriate level of care for strangulation and other history/findings; referrals to psychological counseling, social services, and follow-up care.

Summary: Wartime, Disaster, and Austere Settings

• Utilize trauma-informed care, including any possible privacy measures, respect for patient’s report, and offering the patient autonomy and choice throughout the process.
• Detailed documentation can assist the patient’s future trajectory, including asylum application and can be collected either in a global/internet-accessible database or in paper form if the patient can carry safely,
• Collect a sensitive history, focusing on information that will assist the exam
• If evidence collection and analysis is unfeasible, focus on injury care, infection and pregnancy prophylaxis if indicated, mental health support, and guidance on follow-up needs (e.g. infection surveillance, social services, and mental health referral).

Others relevant Terms

Intimate Partner Violence (IPV): physical, sexual, and/or emotional violence against a romantic partner, including spouse, ex-spouse, girlfriend/boyfriend/significant other, or ex-girlfriend/ex-boyfriend/ex-significant other. Also referred to as “domestic violence.”

Domestic Violence (DV): A longer-used term for IPV, but also may be used more broadly to include other family members.

Gender Based Violence: violence directed against a person because of that person’s actual or perceived gender identity, and/or violence that affects persons of a particular gender disproportionately (63).

Statutory Rape: any sexual act where one of the participants is legally unable to consent, regardless of whether the individual provided assent. This may include individuals who are younger than the legal age of consent in the jurisdiction or individuals who do not legally have cognitive capacity to consent due to intellectual or developmental disability.

Marital Rape/Spousal Rape: rape or sexual assault of one’s own spouse. The term exists to highlight that, increasingly in most jurisdictions, the act of marriage is not sufficient to imply consent and, therefore, nonconsensual sexual activity between spouses constitutes rape. In some jurisdictions, this is not the case.

Reproductive Abuse/Coercion: action(s) to exert control over the reproductive autonomy of another, most commonly a romantic partner. This may include rape and sexual assault, manipulative sexual coercion, manipulative coercion related to pregnancy decision-making (including abortion or continuation of pregnancy), and birth control sabotage (including coercion, fraud, and tampering).

Refugee: someone who is unable or unwilling to return to their country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion (64).

Asylum: Asylum is a protection granted to foreign nationals already in the United States or arriving at the border who meet the international law definition of a “refugee” (64).

Asylum-Seeker: a person who has left their home country as a political refugee and is seeking asylum in another (64).

Mandatory Reporting: the legal obligation to report certain cases to legal authorities in a jurisdiction. This may vary by jurisdiction regarding what is or is not governed by mandatory reporting, e.g. patient report vs. observer concern, age or capacity of patient, specific act/concern, as well as role of the observer individual (e.g. clinician vs. bystander).

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Acknowledgements

Thank you to Lisa Young BS BA, Claudia Taccheri BS, Eric K. Crawford MD PhD, Angelica K. Ezeigwe BS MPH, Megan Hadley MD, Alisha Dziarski BS, Kelly Williams MSN RN, and the many survivors we have met.