From the Guidelines
Sexual assault management in the emergency department requires a comprehensive, trauma-informed approach, prioritizing the patient's physical and emotional well-being, and should include prophylactic treatment for STIs, emergency contraception, and psychological support, as recommended by the CDC and AAP guidelines. The medical evaluation should include documentation of injuries using body diagrams, collection of forensic evidence with a sexual assault evidence kit (within 72-120 hours of assault), and prophylactic treatment. For STI prophylaxis, administer ceftriaxone 500mg IM once for gonorrhea, doxycycline 100mg twice daily for 7 days for chlamydia, and metronidazole 2g orally once for trichomoniasis, as recommended by the CDC 1.
Key considerations in the management of sexual assault include:
- Obtaining informed consent before examination and ensuring a private, safe environment with a chaperone if desired by the patient
- Collecting forensic evidence with a sexual assault evidence kit (within 72-120 hours of assault)
- Providing prophylactic treatment for STIs, including gonorrhea, chlamydia, and trichomoniasis
- Offering emergency contraception options, such as levonorgestrel 1.5mg as a single dose (effective within 72 hours) or ulipristal acetate 30mg as a single dose (effective within 120 hours) 1
- Initiating hepatitis B vaccination if the patient is not immune
- Providing psychological support, including crisis intervention and referral to sexual assault advocacy services
It is essential to note that the risk of HIV transmission from a single episode of sexual assault is low, but HIV prophylaxis should be considered when there is mucosal exposure (oral, vaginal, or anal), and factors such as repeated abuse, multiple perpetrators, and the perpetrator's HIV status should be taken into account 1. Follow-up care should be arranged for 1-2 weeks later to assess medication adherence, provide test results, and continue psychological support. This protocol addresses both immediate medical needs and helps prevent long-term complications while supporting the patient's emotional recovery.
From the Research
Procedure for Sexual Assault in Emergency Department
- The procedure for sexual assault in the emergency department involves providing trauma-informed care to survivors and connecting them with comprehensive services 2.
- Staff preparedness to provide trauma-informed care is crucial, and the presence of sexual assault nurse examiners (SANEs) is highly associated with trauma-informed staff behaviors and comprehensive resources 2.
Medications for Sexual Assault Survivors
- For the treatment of sexually transmitted infections (STIs), ceftriaxone, doxycycline, penicillin, moxifloxacin, and the nitroimidazoles are effective treatments for gonorrhea, chlamydia, syphilis, Mycoplasma genitalium, and trichomoniasis, respectively 3, 4.
- A higher dose of ceftriaxone is now recommended for gonorrhea, and doxycycline is the first-line therapy for chlamydia 3.
- Antimicrobial resistance limits oral treatment options for gonorrhea and Mycoplasma genitalium, and no cure is available for genital herpes 4.
Demographic and Event Characteristics
- Survivors of sexual assault who present to the emergency department are overwhelmingly female, relatively young, often know the perpetrator of the event, and are likely to be threatened and show signs of physical trauma 5.
- Black victims of sexual assault are significantly more likely to be young and know the perpetrator, while physical evidence of trauma is more common among Whites and older persons 5.
- The rate of emergency department visits for sexual assault has increased over time, with female, younger, and lower-income individuals being more likely to present to the emergency department after sexual assault 6.