Definition and Epidemiology

Sexual violence consists of a variety of crimes including rape, sexual assault, and sexual harassment.¹ Sexual harassment includes many types of unwelcome sexual advances, remarks, and gestures. The legal definition of rape according to the Federal Bureau of Investigation (FBI) is “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.” The National Incident-Based Reporting System (NIBRS) defines rape as “The carnal knowledge of a person, without the consent of the victim, including instances where the victim is incapable of giving consent because of his/her age or because of his/her temporary or permanent mental or physical incapacity.”² Sexual assault has a much broader definition. It is defined as any sexual act that is forced or coerced without the consent of the victim, not including penetration.³ Rape and sexual assault are not sexually motivated acts; rather, they are motivated by rage, aggression, and the determination to dominate another human being.

In the United States, a person is a victim of sexual assault every 2 minutes.⁴ According to the National Crime Victimization Survey, 346,830 rapes and sexual assaults of persons aged 12 years or older were reported in 2012.⁵ Further surveys indicate that 1 of 5 women and 1 of 71 men in the United States experience a completed rape at some point in their lifetime.⁶ Despite the general belief that the vast majority of perpetrators are male, a survey of 1058 14- to 21-year-old youths in the United States found that 9% reported having engaged in some form of sexual perpetration; rates of perpetration were similar between males and females by late adolescence.⁷ The rates of sexual assault are higher for female college students, with validated reports of 18% to 20% experiencing some form of sexual assault during their years in college.⁸ These statistics reflect only reported incidents. Sixty percent of sexual assaults are not reported to the police.⁴ The incidence of rape is about 10 times higher for women than for men, although men are less likely to report the occurrence. (For the purpose of this chapter, the term she is used, although this information can also apply to men who have been victims of sexual assault.)

There are no known absolute risk factors for becoming a victim of sexual assault. In fact, anyone can be a victim regardless of age, race, gender, or socioeconomic status. However, sexual assault victims are predominantly female, and the perpetrators are almost always heterosexual males. Female victims are more likely to be assaulted by someone they know, and reports indicate that 63% of sexual assault victimizations involve offenders with whom the victim had a relationship as a family member, intimate, or acquaintance.⁴ Among developmentally disabled adults, up to 83% of women and 32% of men are victims of sexual violence; of these victims of sexual violence, 49% will experience 10 or more abusive incidents.⁹

Sexual assault can also occur in the context of any intimate partner relationship. This includes marital, nonmarital, gay, lesbian, or past relationships. However, these sexual assaults are often recurring and one of the symptoms of a larger domestic violence problem that needs to be addressed. Consequences for ongoing sexual violence by an intimate partner are severe and require ongoing monitoring and attention by the health care provider.

Clinical Presentation

The physical presentation of a patient in the clinic or office setting who has been sexually assaulted is immensely varied. Some patients may report a chief complaint of sexual assault to their health care provider, whereas others may not mention that a sexual assault has occurred. Likewise, the presentation of psychological effects of trauma also varies among victims, ranging from visibly shaken and crying to appearing calm. Some patients may choose to disclose that a sexual assault occurred if they are asked by a trusted health care provider. However, other patients may deny that violence occurred despite evidence of trauma. Whatever the reasons for the patient’s denial, the health care provider must respect it and offer compassionate support. Reassuring the patient that sexual assault is always an act of control and violence and is never something anyone “deserves” or “asked for” is crucial for emotional support.

The health care provider does not need to make a final determination whether sexual assault has occurred; that must be left to the court to decide if the patient opts to report the assault. However, reporting to the police should be encouraged. It is helpful for the provider to let the patient know that sexual assault is, unfortunately, a common experience and that it is a problem the provider may be able to assist with. This may leave the door open should the patient decide in the future to disclose what happened. Unfortunately, in a national study, most rape and sexual assault victims were not treated for their injuries.⁵ According to this study, only approximately 30% of victims received treatment, with 20% of this total receiving care at a physician’s office or clinic.⁵ Health care providers are mandated to report sexual assault of children (state laws vary on age limit), the elderly, and the disabled.

Physical Examination

If the patient does disclose a sexual assault, the provider should defer a physical examination and refer the patient to the emergency department if the sexual assault occurred within the past 5 days, preferably within 72 hours. A referral to the emergency department will ensure that the appropriate measures are taken to collect evidence and to comply with standardized protocol. This is essential to support the patient’s current or future desire for legal pursuits, because some patients may decide later to report the incident to the police. This specialized forensic examination should be free of charge because federal and state funds are available. Having this examination and collection of evidence completed does not require the patient to press criminal charges or to report the incident to law enforcement. Testing for drugs that might have been used to render the patient unaware of what was happening can also be done at no cost to the patient. Furthermore, the emergency department will also be able to provide the patient with comprehensive and compassionate services, including crisis intervention, rape counseling, and referrals to appropriate community agencies. In many emergency departments, there are specially trained nurses (sexual assault nurse examiners [SANEs] and sexual assault forensic examiners) who help provide the patient with appropriate sensitive care.

The health care provider can prepare the patient for what to expect in the emergency department. It is not important that the provider request specific information about the assault; this information will be gathered in the emergency department. Retelling of the story can be traumatizing for the patient. Rather, providers can attentively listen and document what the patient desires to express, using exact quotes whenever possible. The health care provider should carefully note emotional responses (e.g., crying, restlessness, anxious behavior, shaking, withdrawal) because this would be useful in court as an adjunct to the emergency department records. It is important to advise the patient not to shower, urinate, brush teeth, or wash clothing that might contain evidence.

If the patient does not desire to pursue an examination in the emergency department or if more than 5 days have passed since the assault, medical care can be managed in the office setting. The provider needs to obtain a detailed history and perform a full physical examination and gynecologic examination. About 40% of rape victims sustained a collateral injury; 5% sustained a major injury, such as severe lacerations, fractures, internal injuries, or unconsciousness.¹⁰ Injuries are most common among victims aged 30 years or older.¹⁰ Possible gynecologic injuries include vaginal or anal tearing, rectal bleeding, bruising, and soreness. Other physical symptoms associated with trauma include gastrointestinal irritability, dysmenorrhea, pelvic pain, and urinary tract infection. (For specific treatment considerations, see chapters that address the specific injury, infection, and medical disorder.)

When the patient prefers to have a physical examination in the primary care office, the provider should assure her that the examination can stop at any time and that there is time to take a break if needed. The examination that should be performed is a complete head-to-toe examination observing for any injuries, because the patient may not be aware of abrasions or bruising in areas not visible to her. If any injuries are discovered, it is important to measure them with a ruler for documentation. Using the face of a clock to reference areas in the genitalia with the clitoris at the 12-o’clock position and the anus at the 6-o’clock position, the provider documents any abnormal findings. In particular, one should closely examine the posterior fourchette because it is frequently an area in which injuries such as lacerations and abrasions occur.^10,11 Culture specimens are obtained for gonorrhea and chlamydia testing; serum testing for syphilis, hepatitis B and C, and human immunodeficiency virus (HIV) infection and pregnancy is discussed as appropriate (see later).