What are the key components of a comprehensive assessment for a patient presenting to the Emergency Department (ED) after a sexual assault?

Critical Assessment Questions for Sexual Assault Patients in the ED

The most critical assessment questions for sexual assault patients in the ED must address immediate safety, physical injuries, pregnancy/STI risk, mental health crisis, and forensic evidence preservation—in that specific order of priority to prevent mortality and severe morbidity.

Immediate Safety Assessment (First Priority)

Directly ask about current safety threats before proceeding with any medical evaluation. 1

• "Are you safe to leave here today? Do you have concerns about the perpetrator, their friends, or others?" 1, 2
• "Have you been threatened? Are you afraid of anyone right now?" 1
• "Does the perpetrator or their friends have a history of violence or access to weapons?" 1

These questions directly impact whether the patient can be safely discharged and must be asked before focusing on medical or forensic concerns. 2

Mental Health Crisis Screening (Second Priority)

All sexual assault victims must be immediately screened for suicidal and homicidal ideation, as they have significantly elevated rates of self-harm. 1, 2

• "Are you having thoughts of hurting or killing yourself?" 1
• "Are you having thoughts of hurting or killing anyone else?" 1
• "Have you engaged in any self-harm behaviors like cutting or restricting food?" 1

Sexual assault survivors demonstrate markedly increased rates of depression, suicidal ideation/attempts, self-mutilation, and eating disorders. 1, 2 If the provider is uncomfortable performing this assessment, immediate psychiatric consultation is mandatory—not optional. 1

Physical Injury Assessment (Third Priority)

Ask specific questions about injuries that may require immediate treatment before forensic examination. 1

• "Where on your body are you experiencing pain right now?" 1
• "Do you have any bleeding, difficulty breathing, or severe pain anywhere?" 1
• "Were you hit, choked, or injured in any way during the assault?" 1

Nongenital injuries may be life-threatening and take priority over forensic evidence collection. 1

Pregnancy and STI Risk Assessment (Fourth Priority)

Obtain specific information to guide prophylaxis decisions within critical time windows. 1, 3

• "When was your last menstrual period? Is there any chance you could already be pregnant?" 1, 3
• "What type of sexual contact occurred—vaginal, anal, oral, or contact with genitalia?" 1, 3
• "Did ejaculation occur, and if so, where?" 1, 3
• "Have you had any recent consensual sexual contact? When?" 1

This last question about consensual contact is essential for interpreting physical findings correctly during forensic examination. 1 Emergency contraception must be offered within 120 hours, making timing critical. 1, 2

Forensic Evidence Preservation Questions (Fifth Priority)

Ask these questions immediately to preserve evidence, ideally within 72 hours but potentially up to 4-7 days. 1, 3

• "When exactly did the assault occur? What date and approximate time?" 1, 3
• "Since the assault, have you changed clothes, bathed, showered, eaten, drunk anything, urinated, defecated, or douched?" 1

Even if the patient has done these activities, they should still be encouraged to proceed with examination and evidence collection. 1 DNA amplification techniques can identify foreign DNA for at least 72 hours and possibly longer. 1, 3

Critical Consent and Reporting Discussion

Explicitly inform the patient that medical care is provided regardless of their decision about forensic examination or legal reporting. 1

• "You can receive all necessary medical treatment even if you choose not to have evidence collected." 1
• "Having evidence collected does not require you to report to police or press charges. Evidence can be held for 2+ years while you decide." 1

This distinction is paramount—many patients fear they must commit to legal action to receive medical care, which is false. 1

Common Pitfalls to Avoid

• Never delay safety assessment for medical evaluation. An unsafe discharge can result in homicide. 1, 2
• Never skip mental health screening. Suicide risk is dramatically elevated in this population and requires immediate intervention. 1, 2
• Never assume a normal anogenital exam means assault didn't occur. The majority of sexual assault victims have unremarkable examinations. 1
• Never pressure patients into forensic examination. This creates retraumatization and violates trauma-informed care principles. 1, 2
• Never forget to ask about recent consensual contact. This information is essential for accurate interpretation of physical findings and prevents misattribution of injuries. 1