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Complex Situations (SLO7)
Question 48 of 148
You are attending an ED teaching session on sexual assault. Which of the following statements is correct regarding sexual assault injury in females?
Answer:
Genital injury can be seen following consensual and non-consensual intercourse; its presence or location of injury does not confirm that a rape occurred. Non-consensual intercourse (sexual assault) is more likely to result in more injuries that can be more severe. Other bodily injury can be commonly seen and may be more common than genital injury. Injury can be influenced by age, virginal status, resistance, force, number of assailants, and relationship of the assailant to the victim.Sexual Assault
Complex Situations (SLO7) / Obstetrics & Gynaecology / Sexual Health
Last Updated: 9th January 2024
Definitions
- In England and Wales, under the Sexual Offences Act 2003 the definition of rape is the non-consensual penetration of vagina, mouth or anus by a penis.
- Sexual assault by penetration is the non-consensual, intentional insertion of an object or part of the body other than the penis into the vagina or anus.
- The Act also treats any sexual intercourse with a child under the age of 13 as rape and defines the age of consent as 16.
Epidemiology
- Only a minority of sexual assaults are reported to the police. Sexual offences are common, but infrequently present to Emergency Departments, though accurate data is lacking.
- While the majority of assaults are against women of childbearing age, children, the elderly and men can be victims too.
- The majority of assailants are known to the victims and a large numbers of cases are associated with drinking alcohol.
- Sexual assault may not be disclosed initially and the treating clinician should be suspicious when there is domestic violence and in patients requesting for emergency contraception.
Consequences of sexual assault
Sexual assault and rape may result in:
- Physical injuries
- Sexually transmitted infections including HIV and Hepatitis B
- Unwanted pregnancy
- Psychological symptoms, which may culminate in post-traumatic stress disorder and affect immediate family or partners. These can range from sleeping difficulties, poor appetite, flashbacks, feelings of numbness, anger, shame and denial, avoidance behaviour, depression, suicidality, self-harm, relationship and sexual difficulties.
Assessment
- Where possible and practical, victims of sexual assault and rape should be assessed in a Sexual Assault Referral Centre (SARC). A SARC is a one-stop location where victims of sexual assault can receive a forensic examination, emergency contraception and post exposure prophylaxis, psychological counselling, legal advice and other support, from professionally trained staff.
- Patients who present to the Emergency Department should be assessed for physical injuries that may require treatment. Treatment of associated immediate life threatening injuries takes priority over forensic examination.
- If a victim is unwilling to attend a SARC, Emergency Department staff should respect that decision and be able to manage emergency contraception and sexually transmitted infection risks. Assessment should be conducted in a non-judgemental, confidential and supportive manner. The medical assessment should ideally be performed by the most senior or appropriately trained doctor in the emergency department. Patients should be offered a choice of gender of the doctor where possible.
- Take a careful history of the assault including time and location of the assault, characteristics of the assailant(s), physical violence, sexual acts (vaginal, oral, anal; penile/digital penetration). Particular effort should be made to take accurate and contemporaneous notes.
- Examine the body including inside the mouth looking for bruising, abrasions, and lacerations and any patterns such as fingertip marks. Look and treat for any bite marks. Do not attempt any form of pelvic examination unless there is significant bleeding, as this may disrupt any forensic evidence that may be taken at a later date. Document examination findings clearly as you may be asked to produce a statement later or go to court if the victim decides to press charges at a later date.
- There is no requirement for emergency physicians to take pre-transfusion blood samples for the police. Any forensic examination or collection of evidence should only be performed by a clinician with suitable specialist training in an appropriate environment, usually a forensic medical examiner (FME). If the patient is going to be examined by a FME after their injuries have been dealt with, advise the patient to avoid showering, brushing teeth and preserve the clothes worn until they have been examined.
- Consider the possibility of pregnancy or exposure to sexually transmitted infections and the need for emergency contraception or post exposure prophylaxis.
- Victims may need further referral to Social Services, Victim Support, a Community Safety Unit or other organisations which can offer them support after the assault.
- Any concerns about child welfare or vulnerable adults should lead to the activation of local safeguarding procedures.
Exposure to bloodborne viruses
- Assessing exposure to infections is often difficult and the donor is rarely available or willing to provide samples for testing. Where there is a reasonable chance that the patient has been potentially exposed to sexually transmitted infections, prophylaxis should be offered.
- Expert advice should be sought from the relevant on-call service. This varies between organisations, but is usually from the Genitourinary medicine or infectious diseases services.
- Baseline blood tests should be taken for Hepatitis B, Hepatitis C and HIV in the ED.
- Hepatitis A:
- Post exposure vaccination for Hepatitis A following sexual assault would only be recommend
if within two weeks of a contact of a confirmed case or one week after onset of jaundice in
the index case.
- Post exposure vaccination for Hepatitis A following sexual assault would only be recommend
- Hepatitis B:
- If the perpetrator is not known to be Hepatitis B negative, then accelerated Hepatitis B vaccination should be considered. Ideally, immunisation should commence within 24 hours of exposure, although it should still be considered up to a week after exposure.
- As vaccine alone is highly effective, the use of HBIG in addition to vaccine is only
recommended in high-risk situations or in a known non-responder to vaccine.
- HIV:
- The decision to offer Post Exposure Prophylaxis after Sexual Exposure (PEPSE) is not always straightforward.
- If the patient presents within 72 hours of sexual assault, then a risk assessment for acquisition of HIV should be performed. Use of PEPSE is recommended where there is a risk of HIV transmission of over 1 in 1000, and PEPSE should be started as soon as possible.
- Clinicians should bear in mind that transmission of HIV is likely to be increased by physical genital injury, presence of bleeding or by multiple assailants.
- Emergency departments should have access to PEPSE. Patients who receive PEPSE should be followed up by an appropriate service, usually the Genitourinary medicine service who will decide whether to continue PEPSE.
Exposure to bacterial infections
- Transmission of sexually transmitted infections is more likely where there are multiple assailants, biting, defloration, wounds, or anal intercourse. Transmission is also likely when the assailant is a man who has sex with men, or injects illegal drugs.
- Tests for STIs should be offered after sexual assault as described in the current BASHH guidance on testing for STIs. Consider appropriate incubation periods and offer appropriate testing.
- Prophylaxis for bacterial STIs should not be routinely recommended, but could be considered in certain cases.
- Genitourinary medicine follow-up should be offered as the initial assessment may be too early for most sexually transmitted infections to be evident.
Pregnancy Risk Assessment
- Assess all those reporting sexual assault for risk of pregnancy and provide appropriate
testing for pregnancy and assessment for emergency contraception (EC), if required
provide EC following the FSRH guidelines on emergency contraception.
Information sharing
- Emergency physicians should assume that clinical information is confidential. Patients should be offered police involvement, but any decision not to involve the police should be respected.
- In exceptional circumstances, information can be shared with the police and statutory agencies such as social services. These circumstances include:
- Where the victim is a child. Any sexual assault of a child should trigger local safeguarding procedures.
- Where there are concerns about the welfare of children of the victim.
- Where the victim lacks capacity and is unlikely to regain capacity.
- Where guns or knives have been used by the perpetrator.
- The decision to share information with outside agencies should be taken by the supervising Consultant and ideally discussed with another Consultant. Clear documentation of a decision to share information should be documented in the patient’s case notes and this should be communicated to the patient, where practical.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
