Sexual Assault Aftercare in the Emergency Department

Context

The Crime Survey for England and Wales (CSEW) estimated that by end of 2017 20% of women (3.4 million) and 4% of men (631,000) had experienced some kind of sexual assault since the age of 16⁴. Around 90% of perpetrators are known to victims³.

In 2013, An Overview of Sexual Offending in England and Wales³ estimated that 85000 women and 12000 men aged 16-59 experience rape, attempted rape or assault by penetration every year, equating to 11 offences an hour. Only 15% of these offences are reported to the police³.

Many victims will present to the Emergency Department (ED); this RCEM Learning session will summarise guidelines and evidence surrounding their management in the acute setting.

Recommendations are drawn from the RCEM Best Practice Guidelines⁵.

Definition

The Sexual Offences Act 2003² defines rape and sexual assault in England and Wales. Under this legislation:

• The age of consent is defined as 16
• Intentional penetration of a child under the age of 13 is defined as rape
• Rape is defined as non-consensual penetration of the vagina, mouth or anus by a penis
• The non-consensual, intentional insertion of an object or part of the body other than the penis into the vagina or anus is defined as sexual assault by penetration.

Consequences of rape and sexual assault are far-reaching. They include, but are not limited to:

• Psychological harm
  • Post-traumatic stress disorder
  • Anxiety
  • Depression
  • Self-harm or suicide ideation, plan or acts
  • Sleeping difficulties
• Physical harm
  • Exposure to blood-borne viruses such as HIV and Hepatitis B
  • Exposure to sexually transmitted infections
  • Pregnancy
• Social harms
  • Relationship and sexual difficulties
  • Time off work or education
  • Destruction of sense of community and safety

Learning bite

Physical trauma is often associated with sexual assault⁶. When risk-stratifying each patient, remember to assess for non-urogenital trauma.

Sexual Advice Referral Centres

Sexual Assault Referral Centres (SARCs) are a specialised service with professionally trained staff who offer:

• Forensic examination by a qualified practitioner
• Emergency contraception
• Post-exposure prophylaxis
• Psychological counselling
• Legal advice

Benefits of the SARC model include the collaboration of legal and medical agencies in one department, easing victim experience and allowing for collection of information with an intact chain of evidence. Victims can also decline police involvement and be treated anonymously.

However, SARCs are not equipped to manage acute injuries and illness. The primary role of the Emergency Department is to assess for physical injuries which require immediate medical treatment. Serious and life-threatening injuries take priority over forensic examination.

A patient should be encouraged to attend a SARC where possible, however if they decline to do so, staff in the ED should respect that decision and be able to manage risks such as emergency contraception and sexually transmitted infections.

History

1. Emergency Department staff may be the first and/or only people to which the victim has disclosed the assault. As such, disclosure must be respected and met with sympathy and sensitivity. Clinicians should be aware that the absence of injury does not exclude sexual assault or rape, and that their response is likely to significantly impact the patient.
2. Details of the assault should include:
   • Time
   • Location
   • Characteristics of the assailant(s) and/or identity (if known)
   • Physical violence e.g. blunt trauma and relevant sequelae or ongoing symptoms
   • Sexual acts (vaginal, oral, anal; penile or digital penetration)
   • Contraception used or in situ
3. If the assailant is known, the presence of others in their care should be explored, and their safety assessed. Their age and vulnerability should be identified, and risks to wellbeing flagged to the most senior doctor in the department urgently.

Learning bite

The most senior or appropriately qualified doctor should undertake the medical assessment.

Patients should be offered a choice of clinician gender where possible.

Examination

1. Pelvic examination should only be undertaken by a forensic medical examiner (FME) unless there is significant bleeding or other injury which requires immediate medical intervention. This is to reduce the risk of forensic evidence contamination.
2. On rare occasions, the forensic medical examiner may attend the ED to collect evidence, for example if the physical injuries sustained by the victim require ongoing management. ED clinicians should:
   • Take steps to facilitate their attendance in the context of victim consent and/or the context of a best interest decision if the patient lacks capacity to consent.
   • Wear appropriate personal protective equipment (PPE), including gloves, to avoid contaminating evidence.
   • Take care not to cut through areas of clothing which may be used as evidence, such as stab holes, tears or blood stains.
3. Patients should be advised not to shower, brush their teeth, wash or dispose of clothing until they have been examined by an FME, should they consent to do so.
4. In the department, clinicians should examine for bruising, lacerations, abrasions and bite marks.

All history and examination findings should be documented contemporaneously and acted upon in a time-appropriate manner.

Learning bite

In the absence of life-threatening haemorrhage or injury requiring immediate medical intervention, pelvic examination should only be performed by a forensic medical examiner.

Pre-transfusion samples

Unless indicated for blood-borne virus screening, there is no requirement for pre-transfusion blood samples to be taken from victims of sexual assault and rape.

Should the police request this, it should be undertaken by a suitably trained medical professional who can assure the chain of evidence; this is usually the forensic medical examiner.

Other investigations

Other investigations should be requested and acted upon in line with clinical need; for example, a group and save or crossmatch might be requested for a patient who is catastrophically bleeding, or a CT facial bones might be performed in a patient with evidence of facial trauma.

Learning bite

Routine swabs to screen for sexually transmitted infections should be avoided, as they may disrupt forensic evidence and are unlikely to return a positive result so close to exposure.

In the ED

Emergency management of physical health should be performed as per the presenting complaint(s), with focus on resuscitation and stabilisation of the patient.

Safeguarding concerns should be raised to the most senior doctor in the department at the earliest possible moment, and the appropriate services contacted according to local protocols (details below).

Where indicated, emergency contraception should be offered in the ED. This decision should be guided by the sex of the victim and the perpetrator, as well as the nature of the offence. Remember that SARC attendance might be delayed or disrupted, and consider offering emergency contraception with this in mind.

Up to 72 hours after the assault offer Levonorgestrel 1.5g as a stat dose (Levonelle). Ulipristal acetate (EllaOne) and copper intrauterine contraceptive device (Cu-IUD) are licensed for use as emergency contraception for up to 5 days, and where EC is indicated you should advise that Cu-IUD is the most effective form of emergency contraception. More detailed advice is available in this FSRH EC guidance.

Learning bite

For patients with a BMI > 26 or a weight > 70kg, there is evidence that levonorgestrel has reduced efficacy. In this group of patients, offer ulipristal acetate or a double dose (3g) of levonorgestrel.

Risk assess the victim for exposure to blood-borne viruses. This may differ from usual exposure policies, as the donor might not be known, or be unwilling to attend for testing.

Blood-borne virus screening

Where there is a reasonable risk that the patient may have been exposed to blood-borne viruses, and PEP is being initiated, baseline blood tests should be taken in the ED for Hepatitis B, Hepatitis C and HIV.

Hepatitis B

If the perpetrator is not known, or not known to be Hepatitis B negative, accelerated Hepatitis B vaccination should be considered. This consists of one dose in the ED and two further doses with the General Practitioner or the sexual health clinic at 7 days and 21 days post-exposure.

Tetanus

Give Revaxis if there are tetanus-prone wounds and the patient is not fully immunised (5 doses, the most recent within 10 years).

HIV

Post-exposure prophylaxis after sexual exposure (PEPSE) can be effective in reducing transmission of HIV when initiated within 72 hours of exposure, however earlier administration is associated with improved efficacy.

PEPSE should be initiated in the ED and followed up by appropriate services such as a sexual health or GUM service.

Seroconversion can now be detected at 4 weeks post-exposure thanks to fourth generation HIV testing.

Learning bite

PEPSE should always be considered in the event of:

• Known HIV+ status of perpetrator
• Perpetrator has risk factors for HIV infection
• Anal rape
• Multiple assailants
• Bleeding post-assault/ rape.

Bacterial infections

Risk factors for sexually transmitted infections include multiple assailants, biting, defloration, wounds or anal penetration. Perpetrator risk factors for bacterial infection include men who have sex with men or intravenous drug users.

Prophylactic antibiotics should be offered; this may vary from trust to trust, but often takes the form of

• Cefixime 400mg +
• Azithromycin 1g +
• Metronidazole 2g

These are given as oral doses. If the patient is pregnant, metronidazole can be omitted, although specialist opinion is recommended.

Follow-up

Referral to appropriate services should be offered and enacted following victim consent. This may include social services, Victim Support, a Community Safety Unit or other organisations.

In the event of risk factors for blood-borne virus or bacterial exposure, consider follow up with a sexual health/ GUM clinic in 2-3 weeks, or earlier if PEP has been started, as per local protocol.

Psychosocial care can often be provided by a SARC; however, if a patient declines SARC involvement, the patient can be referred to their GP for ongoing support.

If there are immediate concerns regarding the patient’s mental health, risk of suicide or self-harm, local liaison psychiatry teams should be involved in patient care while they are in the ED.

Information sharing

There are many cases where clinicians will be asked to share information with outside agencies; there are fewer where this is a legal requirement regardless of patient consent¹.

Often, the latter refer to sharing information with statutory agencies such as the police or social services. This is indicated if:

• The victim is a child (under the age of 18). Any sexual assault of a child should trigger local safeguarding procedures as per local protocols, and should be reported to the police.
• Where there are concerns about the welfare of children (<18) of or in the care of the victim (safeguarding referral as a minimum, consider police referral if risk of significant imminent danger).
• Where the victim lacks capacity and is unlikely to regain it, a safeguarding referral is indicated.
• Where guns or knives have been used by the perpetrator, police referral is a legal obligation.

Any decision to share information with outside agencies should be made by the supervising Consultant, and ideally discussed with at least one other Consultant. The discussions surrounding this decision should be clearly documented in the patient’s case notes and communicated to the patient where possible.

1. National Institute for Health and Care Excellence. Domestic violence and abuse: Scenario: Managing domestic violence and abuse | Management | Domestic violence and abuse. | CKS | NICE. 2018. [Accessed 14 December 2021].
2. Legislation.gov.uk. 2021. Sexual Offences Act 2003. UK Public General Acts. 2003. [Accessed 14 December 2021].
3. Ministry of Justice, 2013. An Overview of Sexual Offending in England and Wales. Gov.UK, pp.16-17.
4. Ons.gov.uk.  Sexual offences in England and Wales – Office for National Statistics 2017. 2017. [Accessed 14 December 2021].
5. Royal College of Emergency Medicine. Management of Adult Patients who attend Emergency Departments after Sexual Assault and / or Rape. 2015. [Accessed 14 December 2021].
6. Sugar NF, Fine DN, Eckert LO. Physical injury after sexual assault: findings of a large case series. Am J Obstet Gynecol. 2004 Jan;190(1):71-6.