Sexual assault is a major worldwide public health and human rights concern with possibly disastrous short- and long-term effects on mental and physical health. Using rape as a weapon of war to sexual assault occurring within long-term relationships are all examples of sexual violence. Though there is a 20% lifetime risk of sexual abuse against women, men and children can also be impacted.
Vulnerable women are disproportionately the victims of sexual assault, which is also associated with alcohol use. Most complainers are aware of who their attacker is.
Legal definitions of sexual offences: the UK’s and other countries’ laws controlling sexual behaviour differ. A rape is the non-consensual invasion of the vagina, mouth, or anus by a penis (both sexes can be raped). Lawfully speaking, penetration with anything other than a penis is not rape; nonetheless, other accusations (such as “sexual assault by penetration”) might be made. Legal advice clearly explains what permission means. The legal structures also cover child sex abuse.
Agencies: Although victims of sexual assault (also known as “complainants”) may come to a number of agencies, sexual assault is typically initially reported to the police. Local police can conduct a forensic examination (clients are frequently seen in a Family Protection Unit – FPU) or, more and more, in a Sexual Assault Referral Centre (SARC).
Specialist medical and forensic services known as SARCs treat anyone who has been sexually assaulted or raped. Service users can choose later on whether to involve the police or not by having their forensic samples collected and kept. Most SARCs accept referrals from the police as well as from the public.
Management
Assess for serious injuries
For almost half of those who report sexual assault, there will be corresponding injuries, either genital or non-genital. Everyone should be examined, especially those who have had injuries—genital or not. People should be evaluated and those with substantial trauma or severe injuries needing immediate care should be sent straight away to the relevant facilities (A&E). Over forensic investigation, management of these injuries should come first. Consent does not follow from genital harm being absent.
History taking
As the clinical notes could be used in court, it is imperative to use a tactful, nonjudgmental approach and clear documentation.
Police engagement
Finding out whether the complainant wants to involve the police (report) at this point is crucial. “Third party reporting” is another option in which the incident is reported to the local FPU anonymously. You should still get permission for this. Less than 20% of those in the UK who have been sexually assaulted report it to the authorities. The complainant can report the crime with the right assistance, hence reasons for non-engagement should be carefully investigated.
Forensic medical examination (FME)
- Gathering any tangible evidence or specimens that might be used as proof in the event that criminal charges are brought is the aim of the forensic medical examination (FME).
- To prevent DNA contamination and maintain the chain of evidence, forensically secure settings and adequately qualified personnel must perform FME. Although it can be done up to seven days after the incident, FME should be done as soon as feasible. Table 26.1 summarizes the timescales for DNA persistence.
- The complainant should be told not to eat, drink, or brush their teeth; not to wash or bathe; to keep any sanitary ware and garments (unwashed); and not to pass urine (essential if there is suspicion of drug enabled attack).
- Usually, a proforma documents the FME. All injuries are listed and recorded, and samples—such as swabs of vaginal fluid—are collected.
- Drug-facilitated sexual assaults require the collection of urine within four days and blood within three. If presentation is delayed, a month after drug use, hair analysis can be done.
Some police and military agencies have early evidence kits. To facilitate early DNA evidence and toxicological collection, they include a urine sample pot, mouth swab and mouth rinse.
Immediate care - A case-by-case risk assessment should be done for HIV post-exposure prophylaxis following sexual exposure (HIV PEPSE).
- Should it be recommended, PEPSE should start as soon as feasible and no later than 72 hours following the attack. Starting PEPSE should be preceded by a baseline HIV test.
- Studies have shown that, when administered early and for 28 days, PEPSE can lower the risk of HIV acquisition following sexual assault by over 80%.
- HBV PEP: this can start six weeks after an attack if you haven’t already had the vaccination. Follow an expedited timetable. In a non-immune person, HBV immunoglobulin can also be considered ideally within 48 hours but up to 7 days after a single high-risk exposure.
- Emergency contraception (EC): if suitable, a CU-IUD or hormonal EC should be provided after a pregnancy risk assessment.
- STI testing and prophylaxis: baseline testing is available; but, a second test must be done fourteen days following the assault. Offers of self-taken or non-invasive swabs can be made to those who choose not to have a speculum examination. The history should help to identify the sampling sites. Consider the benefits against the downsides of antibiotic prophylaxis for STIs, i.e., missed opportunity for PN versus individual likely to default from follow-up
Psychological consequences
Following a sexual assault, anxiety and sadness are typical. Post-traumatic stress disorder (PTSD) may eventually strike a minority of people.
People should be sent to suitable services and informed about regional victim support groups, such as rape crisis.
Follow-up
Repetitive STI and BBV testing outside of the window period and finishing the HBV vaccination program should be scheduled.
Evaluation of the requirement for continuing psychosocial support should take place at follow-up.
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