Basics
Description
- Sexual assault includes any type of sexual contact, regardless of marital status or sexual orientation, between 2 or more individuals in which 1 of those individuals is involved against his or her will.
- Sexual assault can be verbal, visual, physical, or anything that forces a person to join in unwanted sexual contact or attention.
- The force used by the aggressor can be either physical or nonphysical.
- Sexual assault includes stranger assault, acquaintance or date rape, marital rape, and multiple assailants or gang rape.
Epidemiology
Contrary to popular belief, sexual assault does not typically occur between strangers.
Incidence
- Per the National Crime Victimization Survey, conducted by US Department of Justice in 2009:
- Incidence rate of rape: 0.6/1,000 women ages 12 and up (of which 0.3 were completed and 0.3 were attempted)
- Incidence rate of sexual assault: 0.2/1,000 women
Prevalence
- Per the National Violence Against Women Survey by the US Department of Justice:
- 17.6% of women were victims of rape.
- In a nationally representative survey: Perpetrators were reported to be intimate partners (30.4%), family members (23.7%), and acquaintances (20%).
- Per national emergency department data, sexual assaults represented 10% of all assault-related injury visits to the ER by females in 2006.
- 20 " 25% of college women reported experiencing an attempted or completed rape in college.
Risk Factors
Vulnerable groups for sexual assault:
- Adolescents
- Survivors of childhood sexual or physical abuse
- Persons with disabilities
- Persons with substance abuse problems
- Sex workers
- Persons who are poor or homeless
- Persons living in prisons, institutions, or areas of military conflict
Associated Conditions
- Posttraumatic stress disorder (PTSD)
- Psychiatric comorbidity with PTSD: Major depressive disorder, adjustment disorder, other anxiety disorders, substance abuse, sleep disorders, eating disorders, sexual dysfunction, somatization disorders, personality disorders related with childhood sexual abuse
- Sexually transmitted diseases (STDs)
Diagnosis
PTSD (DSM IV-TR) (1)[A]
- The person has been exposed to a traumatic event in which both of following are present:
- Person has experienced, witnessed, or been confronted with, event(s) that involve actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
- Person 's response involved intense fear, helplessness, or horror. Children may have disorganized or agitated behavior.
- Re-experiencing symptoms (must have ≥1)
- Recurrent, intrusive memories of trauma
- Recurrent, distressing dreams of trauma
- Sense of reliving the experience (flashbacks)
- Intense psychological distress at exposure to trauma reminders
- Physiological response at exposure to trauma reminders
- Avoidance and numbing symptoms (must have ≥3)
- Efforts to avoid thoughts or feelings related to the trauma
- Efforts to avoid people, places, or activities related to the trauma
- Inability to recall important aspects of trauma
- Decreased interest in activities
- Detachment from others
- Restricted range of affect (e.g., unable to have loving feelings)
- Sense of having a foreshortened future
- Increased arousal symptoms (must have ≥2)
- Sleep disturbance
- Irritability or outbursts of anger
- Difficulty concentrating
- Hypervigilance
- Exaggerated startle response
- Duration of the disturbance is >1 month.
- Acute: If duration of symptoms is <3 months
- Chronic: If duration of symptoms ≥3 months
- With delayed onset: If onset of symptoms at least 6 months after the stressor
- Disturbance causes clinically significant distress or impairment in social, work, or other important areas of functioning.
Acute stress disorder (1)[A]
- Characterized by symptoms similar to PTSD
- Symptoms occur <1 month after exposure, lasts at least 2 days, but not >4 weeks
- See DSM-IV TR for full diagnostic criteria
Tests
Lab
- Pregnancy test
- Screening for STDs: HIV, chlamydia, syphilis, gonorrhea, trichomoniasis, and hepatitis B and C
Treatment
- Airway, breathing, and circulation
- Basic elements necessary in the care of the victim:
- Create a safe environment
- Place the patient in a quiet and private area
- Do not leave the patient alone
- Speak quietly and move slowly
- Ask permission to perform clinical procedures
- Prepare a secure and safe interview setting, which will facilitate the gathering of informed consent, medical/sexual history, and the physical exam
- Gather history slowly moving from general to more precise questions
- Be aware of retraumatization of victim
- Physical examination
- Complete as soon as possible but with respect to patient 's emotional readiness; these patients should be given high priority upon triage to the ED
- Can be completed regardless of whether the victim has showered, bathed, douched, changed clothing, brushed teeth, etc.
- 2 purposes: Medical and forensic
- Good documentation is essential.
- Document all injuries thoroughly
- Physician can make use of writing, diagrams, sketches, body maps, or photographs.
- Collection of evidence
- Obtain written consent first from the victim
- Clinicians should be aware of requirements and time limits for it to be legally valid in their local community (ranges from within 72 to 120 hours depending on local jurisdiction).
- To collect evidence, each state uses a "rape kit " which contains laboratory and exam forms, and materials for clinical samples.
- Organized to maintain the chain of evidence
- Anticipate the need to duplicate samples or to perform medical procedures at the same time that the evidence is collected
- Most states require physician reporting of sexual assault by notifying local police.
Medication
STD prophylaxis:
- Always offer HIV and STD prophylaxis as ~50% do not return for follow-up care
- Physicians should be familiar with the local laws regarding the reporting of STDs.
- Centers for Disease Control and Prevention (CDC) 2006 guidelines recommend prophylaxis/treatment for:
- Chlamydia " Azithromycin: 1 g PO single dose (safe in pregnancy) or doxycycline 100 mg PO b.i.d. 7 days (not recommended if pregnant)
- Gonorrhea " Ceftriaxone: 125 mg IM single dose; may also treat incubating syphilis
- Trichomoniasis " Metronidazole: 2 g PO, single dose; also treats bacterial vaginosis, as well as Giardia lamblia and Entamoeba histolytica which are anally transmitted
- Hepatitis B " Hepatitis B vaccination should be given unless patient has been previously vaccinated and has documented immunity. Hepatitis B immunoglobulin (HBIG) is not given.
- HIV " Always offer to test in cases of sexual assault. The decision to initiate post-exposure prophylaxis (PEP) is based on whether a significant exposure occurred during the assault. Decisions are individualized, and the clinician should weigh the likelihood of transmission against the potential benefits/risk of treatment. Consult with a specialist in HIV treatment if prophylaxis is considered to determine treatment regimen. Discuss with patient the toxicities of antiretrovirals, the close follow-up necessary, and the benefit of adherence to recommended dosing. Treatment is most effective if begun within 72 hours.
Pregnancy prophylaxis:
- Provide counseling for pregnancy prevention
- Inform victim about risks and interventions
- Test to rule out a preexisting pregnancy
- Offer emergency contraception if pregnancy is a concern:
- Levonorgestrel: 1.5 mg PO 1 dose or
- Ulipristal acetate: 30 mg PO 1 dose
- 99% effective if given within 72 hours of rape
- Failure rate 1%, with potential teratogenicity
Psychopharmacological treatment for PTSD:
- First line " SSRIs (2)[A]:
- Sertraline (Zoloft): Start 25 mg/day PO and taper upward. Usual daily dose 50 " 200 mg. FDA approved for PTSD
- Paroxetine (Paxil): Start 20 mg/day PO and taper upward. Usual daily adult dose 20 " 50 mg. FDA approved for PTSD
- Other SSRIs could be considered:
- Citalopram (Celexa): 20 " 60 mg/day PO
- Fluoxetine (Prozac): 20 " 60 mg/day PO
- Escitalopram (Lexapro): 10 " 20 mg/day PO
- Second line " Other antidepressants (2)[B]:
- SNRIs
- Venlafaxine (Effexor) 75 " 300 mg/day
- Tricyclic antidepressants (TCAs) (effective as monotherapies but can be dangerous if combined with alcohol or overdosed). Examples: Imipramine, amitriptyline
- Atypical antidepressants
- Mirtazapine (Remeron) 7.5 " 45 mg/day
- Monoamine oxidase inhibitors (MAOIs)
- Phenelzine (Nardil): Reserved for treatment-resistant PTSD due to adverse side effects
- Other medications that can be considered (2)[B]:
- Atypical antipsychotics (used as adjunctive treatment to an SSRI or mood stabilizer)
- Olanzapine (Zyprexa): 5 " 10 mg qhs
- Risperidone (Risperdal): 1 " 3 mg/day in divided doses
- Mood stabilizers have not been widely studied but can be helpful to control flashbacks, impulsivity, or intrusive thoughts (carbamazepine, valproic acid, lamotrigine, topiramate, gabapentin)
- Adrenergic-inhibiting agents
- Prazosin: 1 " 3 mg nightly
- Effective in treating nightmares in PTSD
- Benzodiazepines: NOT useful in PTSD treatment and not effective on PTSD core symptoms. Concerns over addiction.
Additional Treatment
Issues for Referral
To mental health provider for counseling
Additional Therapies
- Psychotherapeutic treatments
- Trauma-focused cognitive behavioral therapy (TFCBT) (3)[A]:
- Strong empirical support for efficacy with PTSD symptoms
- May be most effective for addressing the avoidance symptom cluster of PTSD
- Victims benefit from cognitive therapy, especially in dealing with self-blame, anxiety, and sleep disturbances.
- Cognitive " behavioral treatments include education regarding the nature of PTSD, exposure and response prevention to memories of trauma, stress inoculation, and challenging cognitions that may be fixed.
- Eye movement desensitization and reprocessing (EMDR) (3)[A]:
- Strong empirical support for efficacy with PTSD symptoms
- Patient elicits sequences of large-magnitude, rhythmic saccadic eye movements while holding in mind most salient aspects of traumatic memory.
- Results in a lasting reduction of anxiety
- Cognitive assessment of memory is changed.
- Frequency of flashbacks, intrusive thoughts, and sleep disturbances decreases.
- Group therapy (3)[B]
- Rely on active listening and emotional support
- Group sharing of the experience may affect numbness, isolation, fear of isolation, and significantly improves fear and anxiety.
- Hypnosis
- Victims may find relief of fears, feelings of helplessness, anxiety, and social isolation.
- Family/couple therapy (3)[C]
- The reaction of significant others is often to blame and even to reject the victim.
- Frequent responses by partners and parents are feelings of helplessness, anger, frustration, and homicidal fantasies toward the rapist.
- Psychological debriefing
- A small number of semi-structured therapy sessions immediately following the trauma
- Not effective for preventing PTSD but can be effective for treating acute stress disorder
Ongoing Care
Follow-Up Recommendations
After initial post-assault exam:
- Repeat STD examination within 1 " 2 weeks
- Do serologic tests for syphilis and HIV at 6 weeks, 3 months, and 6 months after the assault if initial tests were negative
- Administer follow-up doses of Hepatitis B vaccine at 1 " 2 months and 4 " 6 months post-assault.
- If indicated, counsel patients again on STD symptoms and abstinence from sexual intercourse until completion of prophylaxis.
- Consult with mental health care provider if any worsening or emergence of psychiatric symptoms. If has comorbid PTSD, continue with medication and/or therapy until resolution of symptoms.
References
1 DSM-IV-TR. Washington, DC: American Psychiatric Press, 2000.2Stein D, Ipser J, Seedat S. Pharmacotherapy for post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2009;1:CD002795.3Bisson J, Andrew M. Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2007;3:CD003388. [View Abstract]
Additional Reading
1Davidson J, Jobson KO. Posttraumatic stress disorder. Psychiatric Ann. 2005;35(11):874 " 875.2Luce H, Schrager S, Gilchrist V. Sexual assault on women. Am Fam Physician. 2010;81(4):489 " 495. [View Abstract]3www.ama-assn.org4www.nsvrc.org5www.rainn.org6www.womenshealth.gov
Codes
ICD9
- 995.83 Adult sexual abuse
- V71.5 Observation following alleged rape or seduction
ICD10
- T74.21XA Adult sexual abuse, confirmed, initial encounter
- Z04.41 Encounter for exam and obs following alleged adult rape
SNOMED
- 422608009 sexual assault (finding)
- 39379000 forcible sexual assault (event)
- 248111006 rape - assault (event)
Clinical Pearls
- Sexual assault is a common occurrence.
- Sexual assault is often associated with subsequent PTSD.
- Physicians face a complex set of medical, psychological, social, and legal issues when treating sexual assault victims and must always consider a multidisciplinary treatment approach.
- Always obtain patient 's written consent before collecting evidence.