It is a common misconception that sexual assault or rape is about sex; it is actually an act of violence. It is also a misconception that a victim sets himself or herself up to be sexually violated. Imbibing alcohol and/or drugs may put the victim in a more vulnerable position, but it is never the fault of the victim. Sexual assault can happen to anyone and can be committed by anyone (Table 1).8

Table 1. Sexual Assault Peer Advocate program

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The philosophy of Dartmouth College’s SAPA program is based on the following shared beliefs and values:
1. The victim is never at fault for any assault or violence that they may encounter.
2. Healthy sexual relationships are consensual and never coercive or exploitative.
3. Sexual assault or intimate partner violence can happen to anyone; and sexual or intimate partner violence can be committed by anyone.
4. Every victim is the expert in their own healing process.
5. Sexual violence is a community issue.
Modified from Dartmouth College.8

Acute intervention

Sexual assault is a crime as well as a trauma. Therefore, if the assault is acute, forensic examination should be offered. Collection of evidence does not mean the survivor then must follow through with prosecution, though it does then provide that option. In January 2009, a new provision of the Violence Against Women Act of 2005 provided that all victims of sexual assault may receive a forensic examination at specially equipped medical settings without first being required to report to law enforcement.6 It is important that the initial exam be done in a specially equipped facility by specially trained personnel who can preserve the chain of evidence and perform an accurate and thorough forensic examination. Information about the requirements and training for personnel to provide this type of examination can be obtained from the National Training Standards for Sexual Assault Medical Forensic Examiners.9

The evidentiary exam should be preceded by offering the survivor a rape victim advocate to be with them throughout the exam and should include informed consent, verified with signed consent, before the examination. An interpreter should be present if needed. The examination should include the entire body, and clothing should be collected, labeled, and sealed. The exam should include swabs of body stains and secretions, clippings and/or scrapings of the fingernails, hair collection from the head and pubic area to analyze the root structures and identify any foreign hairs, and blood samples to test for HIV, syphilis, and pregnancy. A full body exam (including oral, vaginal, and rectal exams) should be done. Equipment used may include a colposcope with photographic capability to assess and document injuries to the genital area. A urine sample should be collected within 96 hours if there is suspicion that a drug was used in the assault.6

Treatment options and considerations for an acute sexual assault include sexually transmitted infection (STI) prophylaxis, emergency contraception options, hepatitis B immunization series without hepatitis B immunoglobulin (HBIG), and HIV postexposure prophylaxis if indicated (Table 2).2,6 Resources for follow-up and follow-up appointments should be provided at this initial exam, in writing, as well as verbally.

Table 2. CDC’s sexual assault and STD prevention guidelines

Recommended prophylactic regimens for prevention of infection
An empiric antimicrobial regimen for chlamydia, gonorrhea, and trichomoniasis
  • Ceftriaxone 250 mg IM in a single dose, OR cefixime 400 mg orally in a single dose, PLUS
  • Metronidazole 2 g orally in a single dose, PLUS
  • Azithromycin 1 g orally in a single dose, OR doxycycline 100 mg orally twice a day for 7 days
  • If there is no prophylactic treatment within the first 72 hours, examination for STDs can be repeated within one to two weeks of the assault.
Postexposure hepatitis B vaccination, without HBIG
  • This vaccine should be administered to sexual assault survivors at the time of the initial examination if they have not been previously vaccinated. Follow-up doses of vaccine should be administered one to two and four to six months after the first dose.
The possibility of HIV exposure from the assault should be assessed at the time of the postassault examination.
  • Specialist consultation on postexposure prophylactic medication (PEP) regimens is recommended if HIV exposure during the assault was possible and if PEP is being considered
  • If PEP is started, perform CBC and serum chemistry at baseline (initiation of PEP should not be delayed, pending
results, as PEP should be started as soon as possible and up to 72 hours after the assault if PEP is indicated).
  • Perform HIV antibody and syphilis testing at original assessment; repeat at 6 weeks, 3 months, and 6 months.
Emergency contraception
  • This measure is necessary when the assault could result in pregnancy in the survivor.
Other management considerations
  • At the initial and follow-up exams, patients should be counseled regarding STD symptoms and the need for immediate examination if symptoms occur, as well as the importance of abstinence from sexual intercourse until STD prophylactic treatment is completed
Modified from CDC.2