INTRODUCTION

Sexual assault is defined as any sexual act performed by one (or more) person(s) on another without consent. It may include the use or threat of force. In some cases, the person does not give consent to have sex because he or she is unconscious or otherwise incapacitated. A person may be raped by a stranger, an acquaintance or date, or a family member. Rape is a legal term and in the United States it refers to any penetration of a body orifice (mouth, vagina, or anus) involving force or the threat of force or incapacity (ie, associated with young or old age, cognitive or physical disability, or drug or alcohol intoxication) without consent.

One in three women in the United States will be a victim of sexual assault sometime in her life; 7 to 10 percent of rape victims are male [1]. One in four women will experience rape or attempted rape during her college years. Large population-based surveys indicate a lifetime prevalence of 13 to 39 percent among women and 3 percent among men [2,3]. Only 10 to 15 percent of all sexual assaults are reported to police. Rape victims are less likely to report assault when the assailant is known to them.

Sexual assaults that are facilitated by the use of alcohol and drugs, which in some cases are voluntarily ingested by the victim, are increasingly recognized and are more common than classic forcible assaults among college students [4,5].

This article is intended as a general guide for victims and family members or friends of a person who has been sexually assaulted. You should seek specific guidance about your situation from a person who is experienced in the care and management of crime victims, such as an emergency department doctor or nurse or a sexual assault nurse examiner.

AFTER SEXUAL ASSAULT

After being sexually assaulted, you may have a lot of questions, including:

• Why did this happen to me?
• Could I have prevented this?
• Will I develop an infection or become pregnant as a result of the assault?
• Who should I call first?
• Should I report this to the police?
• Is this reportable?
• Since I was drinking, isn't this my fault?

In all cases, it is important to know that you did not cause the sexual assault. Sexual assault is an act of violence, intimidation, and control. No one ever "deserves" to be assaulted, even if you wore tight clothing or initially showed interest in your assailant. You cannot consent to sex if you are under the influence of alcohol or drugs.

The following steps are recommended after sexual assault:

• Find a safe environment away from the assailant
• Call a close friend or relative – someone who will offer unconditional support
• Seek medical care; do not change clothes, bathe, douche, or brush your teeth until evidence is collected. A complete medical evaluation includes evidence collection, a physical examination, treatment and/or counseling. You do not have to do any part of this evaluation that you do not want to do.
• Discuss filing a police report with a crisis counselor, experienced social worker, sexual assault nurse examiner, or healthcare provider.
• Follow-up with a healthcare provider one to two weeks later
• Seek counseling services
• Inquire about victim compensation services

You should seek medical care, even if some time has elapsed since the event or there is scant or no evidence for collection. A healthcare provider can offer advice on reporting the event, address concerns regarding infection, pregnancy, and safety, and help you to begin to recover.

SEEK MEDICAL CARE

It is important to seek emergency medical care as soon as possible to begin coping with the complex emotional issues surrounding rape. Medical care is usually provided by a doctor and/or a sexual assault nurse examiner (SANE) in a hospital emergency department or medical clinic. Evidence collection may occur up to 120 hours from the assault and occurs with the consent of the patient.

A sexual assault nurse examiner is a specially trained and certified professional who will provide needed care, document the details of the assault, and collect evidence. The nurse can recommend treatment for sexually transmitted infections and pregnancy prevention if needed. In addition, the nurse is available to testify in court [6].

To locate a center that provides medical care after rape, call a local or national sexual assault hotline, available in the United States by calling 1-800-656-4673 (HOPE). Some hotlines offer a trained crisis counselor to accompany you to the hospital; alternately, a supportive friend or family member can go with you.

If the local hospital does not have access to a crisis counselor or sexual assault nurse examiner, ask your physician to collect evidence as part of the physical examination. Laboratory testing may also be needed. (See 'Laboratory testing' below and 'Physical examination' below.)

Reporting sexual assault to the police — Only 16 to 38 percent of rape victims report the rape to law enforcement, and only 17 to 43 percent present for medical evaluation after rape; one-third of victims of rape never report the assault to their primary care doctor [3,7]. For this reason, all victims are encouraged to provide a detailed description of events and allow a thorough physical examination.

In most states, evidence may be collected without reporting to the police. The best chance of collecting accurate information and evidence is within the first 24 hours of the sexual assault, although some states allow evidence to be collected up to five days later. Changing clothes, showering or bathing, eating, douching, going to the bathroom, and brushing your hair or teeth should be delayed until evidence is collected, if possible.

History of events — Care after sexual assault includes talking with a clinician about what occurred before, during, and after the incident, and describing the assailant(s). A sexual assault nurse examiner or another healthcare provider usually conducts this interview with you privately, without family member or friends. After the interview, a physical examination with or without evidence collection may be done.

Physical examination — During a physical examination, a healthcare provider will document any cuts or bruises on your body. The most commonly injured areas include the breasts, external genitals, vagina, anus, and rectum; these areas will be carefully examined, swabbed, and cultured. With your permission, these areas may be photographed. A friend, family member, or crisis counselor may be present during the physical examination if you wish.

In addition, fingernail scrapings and clippings, pubic and head hair samples, and blood and saliva samples are usually obtained. These samples are labeled, packaged, and sealed, along with your clothing and any other evidence, in an evidence collection kit. This kit must be given directly to a police officer or stored in a secure and locked location to ensure that no one tampers with this evidence.

Preventive treatments — There is a small risk of becoming infected or pregnant as a result of sexual assault. The risk that a woman will become infected with HIV after a single episode of consensual vaginal intercourse (not sexual assault) with an HIV infected man is estimated at 0.1 percent, and from a single episode of consensual anal intercourse at 2 percent. The risk of developing HIV from a sexual assault may be higher, especially if your skin is torn or cut, if there was bleeding, or if there were multiple assailants.

The Centers for Disease Control and Prevention (CDC) and other expert groups recommend preventive treatment if your mouth, vagina, anus, or non-intact skin (eg, a cut) was exposed to the assailant's blood or bodily fluids.

• Preventive treatment for gonorrhea, chlamydia, and trichomonas usually includes three antibiotics. (See "Patient information: Gonorrhea (Beyond the Basics)" and "Patient information: Chlamydia (Beyond the Basics)".)
• Preventive treatment for hepatitis B may not be needed if you were previously vaccinated with the full series of three hepatitis B vaccines. If you were not previously vaccinated with hepatitis B vaccine, one dose is given immediately, followed by additional doses one and six months later. (See "Patient information: Hepatitis B (Beyond the Basics)".)
• Preventive treatment for HIV may be recommended if you are evaluated within 72 hours of being assaulted. A healthcare provider will discuss the potential risks and benefits of preventive HIV treatments. Preventive treatments for HIV are not usually recommended if more than 72 hours have passed since the assault. Most emergency departments will provide five days of preventive medication; you are then encouraged to follow-up with a healthcare provider who specializes in the treatment of infectious diseases. See the Center for Disease Control Web site: www.cdc.gov/mmwr/preview/mmwrhtml/rr5402a1.htm.
• If you are female and are seen within five days (120 hours) after sexual assault, ask about medication to reduce your risk of becoming pregnant. The treatment usually includes one dose of a hormone, which is specifically designed to reduce the risk of pregnancy. This treatment does not induce abortion and will not end a pregnancy. (See "Patient information: Emergency contraception (morning after pill) (Beyond the Basics)".)

If you seek care five or more days after being assaulted, you may consider having a copper intrauterine device (IUD) placed to prevent pregnancy. (See "Patient information: Emergency contraception (morning after pill) (Beyond the Basics)".)

Laboratory testing — Testing for chlamydia, gonorrhea, trichomonas, hepatitis B, and HIV is recommended if you have signs or symptoms of one of these infections. However, testing for these infections in the days following the acute assault will only confirm prior infection, not an infection as a result of the assault.

If you are tested for sexually transmitted infections during the evaluation, it is important to understand that the results will become part of your medical record and will be available to the assailant's attorney if the case goes to trial. Thus, the information could potentially be used to discredit you. For these reasons, some victims choose to avoid STI testing at this time and receive prophylactic treatment for STI’s. To locate a clinic that provides anonymous HIV testing in the United States, call 1-800-CDC-INFO (1-800-232-4636).  

If you are female, you may have a blood or urine pregnancy test during your evaluation; testing within five days after sexual assault can tell if you were pregnant at the time of the assault, but does not indicate if you will become pregnant as a result of the assault. The risk of becoming pregnant after assault depends upon several factors, including the timing of your menstrual cycle (table 1). A pregnancy test is recommended at the follow-up visit to determine if you became pregnant as a result of the rape. (See 'Follow-up care' below.)

A blood and urine test to test for drugs (eg, Rohypnol or GHB, benzodiazepines) that can affect your level of consciousness are recommended if you have difficulty remembering events during or after the assault. However, it is important for you to understand that these tests can also provide evidence of drug or alcohol use. The assailant's attorney will have access to these results, and could potentially use this information to discredit you. Discuss the risks and benefits of drug testing with an experienced healthcare provider or sexual assault counselor.

FOLLOW-UP CARE

Most experts recommend that you have a follow-up visit with a healthcare provider within two weeks of the assault. At this visit, you can have follow-up testing, get treatment if needed, and discuss how you are recovering.

Testing for gonorrhea and chlamydia does not need to be repeated if you took preventive antibiotic treatments. Testing for gonorrhea, chlamydia, trichomonas, and bacterial vaginosis may be recommended after the assault if you did not take preventive treatments at the initial evaluation. Testing is also recommended if you develop symptoms of an infection or would like to be tested. (See "Patient information: Symptoms of HIV infection (Beyond the Basics)".)

Testing for pregnancy is recommended four weeks after the initial examination if you took an emergency contraceptive pill. If you did not use this treatment and you do not have your menstrual period on time, a pregnancy test is recommended.

Testing for HIV is usually repeated at six weeks, three months, and six months after the assault. This schedule of testing is recommended because, in some cases, it takes up to six months for the blood test to become positive. (See "Patient information: Testing for HIV (Beyond the Basics)".).

Protecting others — If you are exposed to blood or bodily fluids during an assault, you must understand the importance of preventing the spread of any potential infection to others (for example, sexual partner(s)) during the follow-up period. These measures are especially important during the first three months after exposure.  

During this time, you should use a condom with any sexual activity to reduce the risk of transmitting the potential infection to your partner. Condoms reduce, but do not completely eliminate, the chances of transmitting hepatitis and HIV infection to others. Women should avoid becoming pregnant for three months. Donations of blood, plasma, organs, tissue, or semen are not recommended during the first three months.

EMOTIONAL SUPPORT

Sexual assault victims often need extensive emotional support. Symptoms of anger, fear, anxiety, physical pain, sleep disturbance, lack of appetite, shame, guilt, depression, and intrusive thoughts can develop in the days to weeks following the assault. Many victims are reluctant to seek help because of their fear that thinking or talking about their experience will be too painful. However, most victims find counseling helpful in the process of recovering and moving on with their life.

In the weeks after an assault, some victims develop physical and emotional symptoms, such as pain in the muscles, joints, genitals, pelvis and/or abdomen, lack of appetite, difficulty sleeping, or nightmares. Some victims find it very difficult to resume their habits, lifestyles, and sexual relationships. This collection of symptoms is called the rape trauma syndrome; this can last several months.

A number of treatment options can help you to cope with the complicated emotional issues surrounding sexual trauma. Early treatment may help to reduce your risk of long-term problems with depression, anxiety, or posttraumatic stress disorder. Crisis centers such as the Rape, Abuse, & Incest National Network (www.rainn.org or 1-800-656-HOPE (4673)) can help you to obtain information about resources and qualified providers in your area.

Counseling or psychotherapy — Counseling or psychotherapy can be helpful in dealing with the events of the assault itself as well as the anger, fear, depression, or anxiety that many people feel afterwards.

Several types of healthcare providers provide counseling, including social workers, psychologists, nurses, and psychiatrists. Some people prefer to meet one-on-one with a counselor while others prefer to meet in a group setting with other people who have had similar experiences.

Medication — Antidepressant and/or antianxiety medications may be recommended if you have emotional or psychological problems that are severe or do not improve with counseling alone. Medication can help to manage the following symptoms:

• Intrusive thoughts, nightmares, and flashbacks
• Feeling jumpy or startling easily at sudden noise
• Remaining "on guard" or constantly alert

A class of antidepressant medications called selective serotonin reuptake inhibitors (SSRIs) are often recommended first. Medications in this class include fluoxetine (Prozac®), sertraline (Zoloft®), paroxetine (Paxil®), citalopram (Celexa®), fluvoxamine (Luvox®) and escitalopram (Lexapro®). These medications may be prescribed by an internist, family physician, or other healthcare provider. (See "Patient information: Depression treatment options for adults (Beyond the Basics)".)

In most cases, the antidepressant medication is continued for 6 to 12 months. When you stop an antidepressant, you should taper the dose over two to four weeks to minimize medication withdrawal symptoms.

LEGAL ISSUES

The procedures for reporting and prosecuting sexual assault and collecting evidence vary by state. In the United States, sexual assaults that involve children under 16 or 18 years or elderly people must be reported. Some states require reporting of any and all sexual assaults. In some states, victims are not required to file a police report immediately, while in other states, an evidence kit will not be collected unless the police are notified.

Many states have witness assistance programs that can provide advice on the pros and cons of reporting sexual assault, assistance in navigating the legal system, and financial compensation for the victim.

Information about individual state laws is available online at the United States Department of Justice Office of Violence Against Women website: (www.usdoj.gov/ovw/).

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Care after rape or sexual assault (The Basics)
Patient information: Screening for sexually transmitted diseases (The Basics)
Patient information: Syphilis (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Gonorrhea (Beyond the Basics)
Patient information: Chlamydia (Beyond the Basics)
Patient information: Hepatitis B (Beyond the Basics)
Patient information: Emergency contraception (morning after pill) (Beyond the Basics)
Patient information: Symptoms of HIV infection (Beyond the Basics)
Patient information: Testing for HIV (Beyond the Basics)
Patient information: Depression treatment options for adults (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Blunt genitourinary trauma
Childhood exposure to intimate partner violence
Differential diagnosis of suspected child abuse
Evaluation and management of lower genital tract trauma in women
Evaluation and management of adult sexual assault victims
Evaluation of sexual abuse in children and adolescents
Management and sequelae of sexual abuse in children and adolescents
Nonoccupational exposure to HIV in adults
Prevention of sexually transmitted infections

The following organizations also provide reliable health information [1,8-11]:

• United States Department of Justice Office of Violence Against Women

• (www.usdoj.gov/ovw/)

• United States Department of Health and Human Services

• (http://www.womenshealth.gov/violence-against-women/get-help-for-violence/resources-by-state-violence-against-women.cfm)

• United States Centers for Disease Control

• (www.cdc.gov/violenceprevention/sexualviolence/index.html)

• National Center for Victims of Crime

• (www.ncvc.org/ncvc/Main.aspx)

• Rape, Abuse, & Incest National Network

• (www.rainn.org)
• 1-800-656-HOPE (4673)

• National Library of Medicine

• (www.nlm.nih.gov/medlineplus/healthtopics.html)