CHAPTER 157 Treatment of the Adult Victim of Sexual Assault
Current statistics indicate that a sexual assault occurs every 4 seconds in this country. One in every four women will be sexually assaulted in her lifetime. But not only women are affected: almost 10% of assault victims are male. Sexual assault is the fastest-growing, most frequently committed, and most under-reported violent crime in the United States.
Sexual assault is under-reported for many reasons, including societal misconceptions about the victims of sexual assault, feelings invoked by such an assault, and the burden of reporting an assault. Misconceptions persist, despite enhanced public education, that individuals who are assaulted may have encouraged the act by their behavior, dress, lack of resistance, or previous promiscuity. Complex law enforcement and health care systems are often perceived as being impersonal and nonsupportive. An estimated 75% of victims know their perpetrators, possibly enhancing feelings of embarrassment, guilt, and fear of retribution. These feelings and misconceptions combined with inadequate support systems often prevent a victim from reporting a sexual assault.
The purpose of the medical evaluation after sexual assault is to assess the patient for physical injuries or possible disease, to document injuries, and to collect the necessary evidence. The remainder of the encounter should be used to treat any injuries, to prevent pregnancy and disease, and to find the proper support services for the victim. The examination and treatment should be completed as soon as possible after the assault, especially the collection of evidence. Although an evaluation within 48 hours is preferred, victims are encouraged to see a clinician even if more than 72 hours have elapsed (this still allows a clinician to treat and prevent many problems).
Collaboration between hospitals, community services, and local law enforcement agencies for the establishment of protocols is very helpful, and such protocols will ease victims’ pain and suffering. Primary care clinicians can be instrumental in ensuring that this collaboration takes place. Such collaboration is effective at not only streamlining the evaluation process but for easing the burden of reporting. Some institutions offer 24-hour availability of specially trained and experienced volunteers, such as a nurse on every shift. These volunteers can provide the victim continuous support during the cumbersome process of answering questions and the examination. They can also act as witnesses for the chain of evidence. A supportive volunteer system can offer such simple things as a change of clothing (victims often need to leave their clothing as evidence), which are hugely appreciated by victims.
Indication
Sexual assault requires treatment.
NOTE: Sexual assault is any form of nonconsenting sexual activity. It encompasses all unwanted sexual acts, from fondling to forcible penetration.
Equipment and Supplies
TABLE 157-1 Sexual Assault Kit Equipment*
* Contents should be refrigerated after collection.
Preprocedure Patient Education
If a patient calls before presenting to the emergency department, first make sure that the patient is safe. If not, encourage the patient to call the police. Next, encourage the patient not to take a bath or remove the clothing worn during the assault. If possible, they should postpone urinating, defecating, brushing their teeth, or drinking anything until samples are collected. Also, ask them to bring a change of clothing. Patients should sign for informed consent before starting the evaluation (see the patient consent form available online at www.expertconsult.com).
Procedure
History
Questions should be directed to the victim in a nonjudgmental way, and the patient should be allowed to talk about the assault at a comfortable pace, using her or his own words. It is important to observe nonverbal communication that may indicate a need for further questioning. Supportive terms worth using include “I’m glad you’re alive,” “You did what you needed to survive,” “I’m sorry this happened to you,” and “It was not your fault.” Allow the victim to express her or his feelings. To build rapport, it may be worth obtaining the medical and sexual history before obtaining the assault history.

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