Sexual assault is any type of sexual activity or contact that a person does not consent to. Sexual assault, including rape, may cause physical injury or illness or psychological trauma. Survivors should be evaluated for injury, sexually transmitted infections, pregnancy, and acute or posttraumatic stress disorders; they are asked to give permission for an examination to collect evidence. Treatment includes infection prophylaxis and mental health care.
Sexual assault includes rape and sexual coercion; it may involve physical force or threats of force, or the attacker giving the victim drugs or alcohol.
Although legal and medical definitions vary, rape is typically defined as penetration, no matter how slight, of the vagina or anus with any body part or object or oral penetration by another person's sex organ without the consent of the victim (1). People under the age of consent cannot give consent to sexual activity with an adult.
Typically, sexual assault is an expression of aggression, anger, or need for power; psychologically, it is more violent than sexual. Nongenital or genital injury occurs in approximately 40% of rapes of females (2).
Rape and other forms of sexual assault, including childhood sexual assault, are common; the estimated lifetime incidence for rape in the United States is 19.3% of women and 1.7% of men (3). However, actual incidence may be higher because rape and sexual assault tend to be underreported.
Females have the highest rates of rape and sexual assault; however, victims include people of all genders.
General references
1. US Department of Health and Human Services/Office on Women's Health: Rape. Accessed March 2024.
2. Basile, K.C., Smith, S.G., Kresnow, M., et al: The National Intimate Partner and Sexual Violence Survey: 2016/2017 Report on Sexual Violence. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. June 2022.
3. Breiding MJ, Smith SG, Basile KC, et al: Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization--National Intimate Partner and Sexual Violence Survey, United States, 2011. MMWR Surveill Summ 63(8):1-18, 2014.
Symptoms and Signs of Sexual Assault
Sexual assault may result in the following:
Genital injury
Extragenital injury
Psychological trauma
Hepatitis
Human papillomavirus infection
Other sexually transmitted infections (STIs—eg, syphilis, gonorrhea, chlamydial infection, trichomoniasis)
Pregnancy
Physical injuries may be relatively minor, but some lacerations of the upper vagina are severe. Additional injuries may result from physical violence that occurs during the sexual assault. Evidence indicates that a lifetime experience of rape is also related to long-term physical health problems; for example, risk of developing asthma, irritable bowel syndrome, frequent headaches, dyspareunia, pelvic pain, or chronic pain is higher for people who do versus do not have a history of being the victim of rape (1).
Psychological symptoms of sexual assault are potentially the most prominent. In the short term, most patients experience fear, nightmares, sleep problems, anger, embarrassment, shame, guilt, or a combination. They may be unable to remember important parts of the event (dissociative amnesia, which is a symptom of acute stress disorder or posttraumatic stress disorder [PTSD]).
Immediately after an assault, patient behavior can range from talkativeness, tenseness, crying, and trembling to shock and disbelief with dispassion or quiescence. The latter responses rarely indicate lack of concern; rather, they reflect avoidance reactions, physical exhaustion, or coping mechanisms that require control of emotion. Anger may be displaced onto hospital staff or family members.
For acute stress disorder to be diagnosed, symptoms must be present for 3 days to 1 month after the assault.
Friends, family members, and officials may be supportive or react judgmentally or in another negative way. Negative reactions can impede recovery after an assault.
Long-range effects of sexual assault may include PTSD, particularly among women. PTSD is a trauma-related disorder; symptoms of PTSD include
Re-experiencing the trauma (eg, flashbacks, intrusive upsetting thoughts or images)
Avoidance (eg, of trauma-related situations, thoughts, and feelings)
Negative effects on cognition and mood (eg, persistent distorted blame of self or others, inability to experience positive emotions)
Altered arousal and reactivity (eg, sleep difficulties, irritability, concentration problems)
For PTSD to be diagnosed, symptoms must last for > 1 month, must not be attributable to the physiologic effects of a substance or a medical disorder, and must significantly impair social and occupational functioning. Patients with PTSD often also have depression and/or other psychological disorders (eg, substance use disorder).
Symptoms and signs reference
1. Basile KC, Smith SG, Chen J, Zwald M: Chronic diseases, health conditions, and other impacts associated with rape victimization of U.S. women. J Interpers Violence 36; 23–24; 2021. doi: 10.1177/0886260519900335
Evaluation of the Sexual Assault Victim
The medical evaluation of a sexual assault victim, including victims of rape, should be approached using principles of trauma-informed care (1). Goals of medical evaluation after sexual assault are
Medical assessment and treatment of injuries and assessment, treatment, and prevention of pregnancy and STIs
Collection of forensic evidence
Psychological evaluation
Recommendation of psychological treatment and support
If patients seek advice before medical evaluation, they are told not to throw out or change clothing, wash, shower, douche, brush their teeth, clip their fingernails, or use mouthwash; doing so may destroy evidence.
Whenever possible, all people who are raped are referred to a local rape center, often a hospital emergency department; such centers are staffed by specially trained professionals (eg, sexual assault nurse examiners [SANE]). Some areas in the United States have a sexual assault response team (SART), which includes members from health care, forensics, the local rape crisis center, law enforcement, and the prosecutor's office. Benefits of a sexual assault evaluation are explained, but patients are free to consent to or decline the evaluation. The police are notified if patients consent. Most patients experience the effects of trauma, and their care requires sensitivity, empathy, and compassion. Patients may feel more comfortable with a clinician of the same sex; all patients should be asked about their preference before the examination. A female staff member should accompany all males evaluating a female. Patients are provided privacy and quiet whenever possible.
A form (sometimes part of a sexual assault evidence collection kit) is used to record legal evidence and medical findings (for typical elements in the form, see table Typical Examination for Alleged Sexual Assault); it should be adapted to local requirements. Because the medical record may be used in court, results should be written legibly and in nontechnical language that can be understood by a jury.
History and examination
Before beginning, the examiner asks the patient’s permission. Because recounting the events often frightens or embarrasses the patient, the examiner must be reassuring, empathetic, and nonjudgmental and should not rush the patient. Privacy should be ensured. The examiner elicits specific details, including
Type of injuries sustained (particularly to the mouth, breasts, vagina, and rectum)
Any bleeding from or abrasions on the patient or assailant (to help assess the risk of transmission of HIV and hepatitis)
Description of the attack (eg, which orifices were penetrated, whether ejaculation occurred or a condom was used)
Assailant’s use of aggression, threats, weapons, and violent behavior
Description of the assailant
Many sexual assault reporting forms include most or all of these elements (see table Typical Examination for Alleged Sexual Assault). The patient should be told why questions are being asked (eg, information about contraceptive use helps determine risk of pregnancy after sexual assault; information about previous coitus helps determine validity of sperm testing).
The examination should be explained before each step; the patient may refuse any part of the examination. Results should be reviewed with the patient. When feasible, photographs of possible injuries are taken. The mouth, breasts, genitals, and rectum are examined closely. Common sites of injury in females include the labia minora and posterior vagina. Examination using a Wood’s lamp may detect semen or foreign debris on the skin. Colposcopy is particularly sensitive for subtle genital injuries. Some colposcopes have cameras attached, making it possible to detect and photograph injuries simultaneously. Whether use of toluidine blue to highlight areas of injury is accepted as evidence varies by jurisdiction.
Testing and evidence collection
Routine testing includes a pregnancy test and serologic tests for syphilis, hepatitis B, and HIV; if done within a few hours of sexual assault, these tests provide information about pregnancy or infections present before the sexual assault but not those that develop after the sexual assault. Vaginal secretions or urine is tested for trichomonal vaginitis and bacterial vaginosis; samples from every penetrated orifice (vaginal, oral, or rectal) are obtained for gonorrheal and chlamydial testing (2). Patients may decline STI testing, possibly because empiric therapy is typically given to all patients.
Follow-up tests are done to check for pregnancy and STIs:
At 1 week: Gonorrhea, chlamydial infection, and trichomoniasis in patients who refused prophylactic treatment
At 2 weeks: Pregnancy
At 4 to 6 weeks: Syphilis and HIV infection
At 3 months: Syphilis, hepatitis, and HIV infection
If the patient has amnesia for events around the time of sexual assault, drug screening for flunitrazepam (the date rape drug) and gamma hydroxybutyrate should be considered. Testing for drugs of abuse and alcohol is controversial because evidence of intoxication may be used to discredit the patient.
Patients with severe lacerations of the upper vagina, especially children, may require laparoscopy to determine depth of the injury.
Evidence that can provide proof of sexual assault is collected (see table Typical Examination for Alleged Sexual Assault); it typically includes
Clothing
Smears of the buccal, vaginal, and rectal mucosa
Combed samples of scalp and pubic hair as well as control samples (pulled from the patient)
Fingernail clippings and scrapings
Blood and saliva samples
If available, semen
Many types of evidence collection kits are available commercially, and some states recommend specific kits. Evidence is often absent or inconclusive after showering, changing clothes, or activities that involve sites of penetration, such as douching. Evidence becomes weaker or disappears as time passes, particularly after > 36 hours; however, depending on the jurisdiction, evidence may be collected up to 7 days after sexual assault.
A chain of custody, in which evidence is in the possession of an identified person at all times, must be maintained. Thus, specimens are placed in individual packages, labeled, dated, sealed, and held until delivery to another person (typically, law enforcement or laboratory personnel), who signs a receipt. In some jurisdictions, samples for DNA testing to identify the assailant are collected.
Clinicians should encourage patients to seek help with managing the effects of their trauma and with restoring their ability to function (crisis intervention) and to seek psychological support.
Evaluation references
1. Raja S, Hasnain M, Hoersch M, Gove-Yin S, Rajagopalan C: Trauma informed care in medicine: current knowledge and future research directions. Fam Community Health 38(3):216-226, 2015. doi:10.1097/FCH.0000000000000071
2. Centers for Disease Control and Prevention: Sexually Transmitted Infections Treatment Guidelines, 2021: Sexual assault and abuse and STIs – adolescents and adults. Accessed January 2024.
Treatment of the Sexual Assault Victim
Psychological treatment
When indicated, postexposure hepatitis B and human papillomavirus (HPV) vaccination
Possibly HIV postexposure prophylaxis
Possibly emergency contraception
After the evaluation, the patient is provided with facilities to wash, change clothing, use mouthwash, and urinate or defecate if needed. A local sexual assault crisis team can provide referrals for medical, psychological, and legal support services.
Physical injuries are treated.
Prophylaxis for STIs is prescribed as needed. Vaginal lacerations may require gynecology consultation and surgical repair.
Psychological support
Sometimes examiners can use commonsense measures (eg, reassurance, general support, nonjudgmental attitude) to relieve strong emotions of guilt or anxiety. Possible psychological and social effects of sexual assault are explained, and the patient is introduced to a specialist trained in sexual assault crisis intervention. Because the full psychological effects cannot always be ascertained at the first examination, follow-up visits are scheduled at 2-week intervals. Severe psychological effects (eg, persistent flashbacks, significant sleep disruption, fear leading to significant avoidance) or psychological effects still present at follow-up visits warrant psychiatric or psychological referral.
Family members and friends can provide vital support (eg, gentle encouragement, reminders that the sexual assault was not their fault), but they may need help from sexual assault crisis specialists in handling their own negative reactions.
PTSD can be effectively treated with psychotherapy and pharmacotherapy.
Prevention or treatment of infections
Routine empiric prophylaxis for STIs for adults and adolescents consists of the following (1):
For hepatitis B,
HPV vaccination is given to females and males aged 9 to 26 years if they are unvaccinated or incompletely vaccinated. The vaccine is repeated at 1 and 6 months after the first dose. A 2-dose schedule (at 0 and 6 to 12 months) is recommended for unvaccinated patients who are starting HPV vaccination before age 15 years.
Counseling about empiric postexposure prophylaxis for HIV infection is recommended. Most authorities recommend offering prophylaxis; however, risk factors should be considered, and the patient should be told that on average, the risk of HIV infection after sexual assault from an unknown assailant is low (2). Risk may be higher with any of the following:
Anal penetration
Bleeding (assailant or victim)
Male-male sexual assault
Sexual assault by multiple assailants (eg, male victims in prisons)
Sexual assault in areas with a high prevalence of HIV infection
Prophylaxis for HIV infection is best begun < 4 hours after penetration and should not be given after > 72 hours.
Prevention of pregnancy
Emergency contraception should be offered to all women with a negative pregnancy test (3, 4). Usually, oral medications are used; if used > 72 hours after sexual assault, they are much less likely to be effective. An antiemetic may help if nausea develops. An intrauterine device may be effective if used up to 5 days after sexual assault.
If pregnancy results from sexual assault, the patient should be counseled about options for obstetric care and elective termination.
Treatment references
1. Centers for Disease Control and Prevention: Sexually Transmitted Infections Treatment Guidelines, 2021: Sexual assault and abuse and STIs – adolescents and adults. Accessed January 2024.
2. Welch J, Mason F: Rape and sexual assault. BMJ 334 (7604): 1154–1158, 2017. doi: 10.1136/bmj.39211.403970.BE
3. Cowdery C, Halloran D, Henderson R, et al: Sexual Assault Nurse Examiner and Emergency Contraception Access in Emergency Departments in the United States: A National Survey. Available at SSRN: https://ssrn.com/abstract=3947818 or http://dx.doi.org/10.2139/ssrn.3947818. Accessed January 2024.
4. Wang MJ, Khodadadi AB, Turan JM, White K: Scoping Review of Access to Emergency Contraception for Sexual Assault Victims in Emergency Departments in the United States. Trauma Violence Abuse 22(2):413-421, 2021. doi:10.1177/1524838019882023
Key Points
Sexual assault is any type of sexual activity or contact that a person does not consent to.
Nongenital or genital injury, sexually transmitted infections, and pregnancy may occur.
In the short term, most patients experience fear, nightmares, sleep problems, anger, embarrassment, and other psychological symptoms; although most patients eventually recover; some develop posttraumatic stress disorder (PTSD).
Explain the benefits of a sexual assault evaluation, which the patient can consent to or decline; ask the patient's permission before each step of the evaluation, and explain what each step involves and why it is being done.
Check for injuries, test for pregnancy and sexually transmitted infections, collect evidence that can provide proof of sexual assault (eg, smears of the buccal, vaginal, and rectal mucosa), and maintain chain of custody.
Provide psychological support for the patient and the patient's family, provide prophylaxis for sexually transmitted infections, and offer emergency contraception.
