Behavioral Health

Sexual assault: acute care and forensic considerations

Clinical Overview and When to Suspect Sexual Assault

— ~1 in 5 women and ~1 in 38 men report lifetime contact sexual violence (CDC NISVS)

— >50% of assaults involve a known perpetrator (partner, acquaintance, family member)

— Peak incidence ages 12–34; LGBTQ+, disabled, incarcerated, and unhoused populations at markedly elevated risk

— Drug-facilitated sexual assault (DFSA) increasingly common — ethanol is the most common agent, followed by benzodiazepines, GHB, ketamine

— Vague pelvic, genital, or anorectal pain without clear etiology

— New STI, unintended pregnancy, or request for emergency contraception in a hesitant patient

— Acute PTSD-like presentation, dissociation, self-harm, or substance overdose

— Unexplained injuries (bruising in clothing-covered areas, ligature marks, oral trauma)

— Pediatric/adolescent recurrent UTIs, anogenital complaints, sudden behavior change

— Adult with cognitive impairment and unexplained genital injury (consider elder/vulnerable adult abuse)

— Patient-led pace, explicit consent for each step, minimize retelling

— Offer same-gender provider when possible; allow support person except during forensic interview

— Use neutral, non-judgmental language; avoid "alleged" framing in clinical notes

Definition: Sexual assault encompasses any non-consensual sexual contact, including penetrative rape, attempted penetration, unwanted touching, and contact obtained through force, threat, incapacitation (intoxication, unconsciousness), or inability to consent (minor, cognitive impairment).

Epidemiology highlights:

When to suspect in the ED even if not the chief complaint:

Trauma-informed approach is the standard of care:

Step 3 management: The ED visit has three parallel tracks that must occur simultaneously, not sequentially: (1) medical stabilization and injury care, (2) forensic evidence collection (within jurisdictional window, typically ≤120 hours), and (3) prophylaxis + safety planning. Anchor every decision to these three buckets.

Board pearl: A SANE (Sexual Assault Nurse Examiner) exam is offered, not mandated — the patient may decline forensic collection and still receive full medical care, including prophylaxis and follow-up.

Presentation Patterns and Key History

— Triage to private, quiet space; one provider as primary point of contact

— Confirm patient is safe from perpetrator before extensive history

— Document patient's own words in quotes when possible; avoid leading questions

— Use ED template or SANE-driven interview to avoid repeated retelling (re-traumatization)

— Who: Known vs. stranger, number of assailants, ongoing threat

— What: Specific acts (oral, vaginal, anal penetration; digit/object/penis; ejaculation; condom use; biting; strangulation)

— When: Date/time of assault — drives prophylaxis windows and evidence yield

— Where: Location, surfaces (for trace evidence), restraints

— Weapons/force: Threats, weapons, physical violence, strangulation (red flag for lethality)

— Bathing, douching, urinating, defecating, brushing teeth, eating/drinking, changing clothes

— These reduce but do not eliminate evidence yield

— LMP, contraception, possibility of pre-existing pregnancy

— HIV status, prior STIs, immunization status (hepatitis B, HPV, tetanus)

— Allergies (esp. to prophylaxis drugs: doxycycline, ceftriaxone, antiretrovirals)

— Mental health history, prior trauma, current substance use, suicidality

— Ask specifically: "Did anyone put hands, an arm, or anything around your neck?"

— Symptoms: voice change, dysphagia, neck pain, petechiae, LOC, incontinence

— Even minimal external findings can mask carotid dissection or laryngeal injury

Initial encounter principles:

Core forensic history elements (the "5 W's of assault history"):

Post-assault behaviors that affect evidence (ask but do not shame):

Medical/gyn history relevant to management:

Strangulation screen (often missed, high morbidity):

Key distinction: Forensic history ≠ legal investigation. The clinician's job is to obtain information needed for medical decision-making and to document objectively — not to determine credibility or guilt. Avoid words like "alleges" or "claims"; use "patient reports" or "patient states."

Board pearl: Drug-facilitated assault is suggested by amnestic gaps, waking in unfamiliar surroundings, or disproportionate intoxication for reported intake — collect urine toxicology early (many agents clear within 12–72 hours).

Physical Exam Findings (and Hemodynamic Assessment when relevant)

— Strangulation → airway edema, carotid injury, anoxic brain injury

— Penetrating/blunt trauma → hemorrhage, intracranial injury

— Drug-facilitated assault → altered mental status, respiratory depression, hypothermia

— Trauma vitals (HR, BP, GCS, SpO₂) before forensic exam; hemodynamic instability mandates trauma workup first

— Head/face: Periorbital bruising, lip/oral lacerations, frenulum tears, tooth fractures

— Neck: Petechiae (eyelids, conjunctiva, scalp), linear marks, hand-pattern bruising, subconjunctival hemorrhage, hoarseness, stridor

— Trunk/extremities: Bite marks (swab for DNA before cleaning), patterned bruises, defensive wounds on forearms/hands, ligature marks at wrists/ankles

— Anogenital exam: Often normal even after penetrative assault — absence of injury does NOT exclude assault

— Posterior fourchette tears, fossa navicularis abrasions, hymenal transections (acute)

— Perianal fissures, rectal tears

— Toluidine blue dye or colposcopy enhances detection of microtears

— Document using clock-face orientation (patient in lithotomy: 12 o'clock = anterior)

General principle: Exam serves both medical (identify injuries needing treatment) and forensic (document evidence) purposes. Obtain explicit, stepwise consent. Patient may decline any portion.

ABCs and hemodynamic assessment first — assault may involve major trauma:

Head-to-toe survey, documented with body diagram and photographs (with consent):

Anogenital findings when present:

Step 3 management: In a hemodynamically stable patient, the SANE exam takes priority over non-urgent ED tasks, because evidence degrades rapidly. Coordinate so labs, prophylaxis counseling, and social work happen around — not after — the forensic exam.

Board pearl: A normal anogenital exam is the most common finding in adult sexual assault. Documenting "no injury" should never be framed as evidence assault did not occur.

CCS pearl: Order "SANE consult/sexual assault forensic exam," "photodocumentation," and "body diagram documentation" as discrete CCS-style orders alongside medical workup.

Diagnostic Workup — Initial Labs / Imaging / ECG / Biomarkers

— Pregnancy test (urine or serum β-hCG) — mandatory in all patients with childbearing capacity before emergency contraception

— HIV antigen/antibody (4th-gen) — baseline negative supports later seroconversion claim

— Hepatitis B surface antigen, anti-HBs, anti-HBc — guides vaccination/HBIG decision

— Hepatitis C antibody — baseline

— Syphilis (RPR or treponemal screen)

— NAAT for gonorrhea and chlamydia — site-specific (vaginal/cervical, rectal, pharyngeal based on exposure)

— Wet mount / Trichomonas NAAT if vaginal exposure

— CBC, CMP, coagulation if significant trauma or PEP planned (baseline renal/hepatic function)

— Urine drug screen + expanded panel (GHB, ketamine, benzodiazepines beyond standard immunoassay)

— Serum ethanol level

— Collect ASAP — GHB clears urine within ~12 hours, many benzodiazepines within 72 hours

— Forensic toxicology samples are collected separately by SANE with chain of custody

— CT head for LOC, severe headache, neuro deficit, strangulation with neuro symptoms

— CTA neck for strangulation with neuro symptoms, voice change, or significant external findings — rule out carotid/vertebral artery dissection

— Soft tissue neck CT for suspected laryngeal/tracheal injury

— CT abdomen/pelvis for blunt abdominal trauma, peritoneal signs

— Plain films for suspected fractures

Baseline labs (drawn at presentation; establish pre-exposure status for medico-legal and prophylaxis monitoring):

Toxicology (especially if DFSA suspected or AMS):

Imaging — only as indicated by injury pattern:

ECG and cardiac monitoring if strangulation with LOC, suspected QT-prolonging drug ingestion, or chest trauma.

Board pearl: Strangulation with any neurologic symptom (even transient) mandates CTA of the neck — delayed stroke from carotid dissection can occur days to weeks later.

Key distinction: Clinical STI testing (for the patient's medical care) is distinct from forensic specimens (chain-of-custody swabs for evidence). Both may be collected, but results serve different purposes and are documented separately.

Diagnostic Workup — Advanced or Confirmatory Studies

— Standard window ≤120 hours (5 days) post-assault in most US jurisdictions; some extend to 7 days

— Yield highest within first 24 hours but never refuse a kit based on time alone — defer to local protocol

— Conducted by SANE/SAFE-trained clinician when available; chain of custody documented at every transfer

— Oral, vaginal, cervical, anal, and penile swabs (per exposure history)

— External genital swabs and combings (pubic hair)

— Fingernail scrapings/clippings (defensive evidence)

— Bite mark swabs (saline-moistened, before any cleansing)

— Clothing worn during or immediately after assault (paper bags, not plastic — prevents mold)

— Reference samples: buccal swab or blood for patient DNA

— Known/foreign hair samples, debris

— Hair sample at ~4–5 weeks post-event can confirm single-dose drug exposure

— Blood + urine collected with chain of custody for GC-MS confirmation

— CTA neck for vessel injury

— MRI brain if persistent neuro symptoms with negative CT

— Flexible laryngoscopy for voice change, dysphagia, hemoptysis

— Repeat β-hCG; transvaginal ultrasound if positive

Forensic evidence collection ("rape kit" / SAFE kit):

Typical kit components:

Alternate light source (Wood's lamp, ALS) to identify fluids, fibers, bruising not visible to naked eye.

Colposcopy with photodocumentation improves detection of microtrauma and provides reviewable record.

Advanced toxicology (forensic lab, not clinical):

Strangulation-specific advanced workup:

Pregnancy assessment if delayed presentation (>1 week):

CCS pearl: Order in this sequence on CCS — (1) IV access + trauma labs, (2) urine β-hCG, (3) SANE consult, (4) forensic kit collection, (5) STI NAAT panel, (6) HIV/HBV/HCV/syphilis serologies, (7) targeted imaging. Document chain of custody whenever evidence transfers hands.

Board pearl: Kit collection beyond 120 hours is not automatically futile — DNA has been recovered up to 7+ days from cervix and from clothing/bedding indefinitely if stored properly. Always offer.

Risk Stratification or First-Line Management Logic

— (1) Medical stabilization — treat trauma, strangulation injury, intoxication

— (2) Forensic evidence collection — within window, with consent

— (3) Prophylaxis + psychosocial support + safety

— Pregnancy risk? → Emergency contraception (EC) regardless of cycle day if reproductive capacity

— STI exposure? → Empiric prophylaxis for gonorrhea, chlamydia, trichomonas; consider syphilis

— HIV exposure risk? → Assess source factors + exposure type → offer HIV PEP within 72 hours

— Hepatitis B susceptible? → Vaccinate ± HBIG

— Tetanus status? → Update if wound and last dose >5 years

— Mental health acuity? → Suicidality, intoxication, dissociation

— Safety at discharge? → Return to perpetrator? Housing? Intimate partner violence overlap?

— Highest risk: Receptive anal exposure, known HIV+ source, mucosal trauma, multiple assailants, ejaculation

— Moderate: Receptive vaginal, oral with ejaculation/trauma

— Lower: Oral without ejaculation, condom use without breakage

— Decision: Offer PEP for any meaningful mucosal exposure if presenting within 72 hours; engage in shared decision-making for borderline cases

— Any LOC, incontinence, persistent neuro symptoms, voice change → admit or extended observation + imaging

— Mild symptoms with normal exam → discharge with strict return precautions, strangulation follow-up clinic

Three concurrent priorities (the framework that organizes every decision):

Risk stratification questions that drive management:

HIV PEP risk stratification:

Strangulation triage:

Step 3 management: Empiric prophylaxis is offered, not contingent on positive testing. Waiting for STI results delays treatment past the prophylactic window. Treat presumptively; treat the testing as baseline documentation.

Board pearl: The 72-hour window for HIV PEP and the 120-hour window for forensic evidence are different clocks. Memorize: PEP = 72h, EC (ulipristal/levonorgestrel) = 120h, copper IUD = 120h, forensic kit = 120h (often).

Pharmacotherapy — First-Line Drug Regimen

— Levonorgestrel 1.5 mg PO ×1 — OTC, most effective within 72h, declines after; less effective with BMI >30

— Ulipristal acetate 30 mg PO ×1 — prescription; effective up to 120 hours; preferred for BMI 26–35 and for presentations 72–120h

— Copper IUD — most effective (>99%); can be placed up to 120h; provides ongoing contraception

— Levonorgestrel 52 mg IUD — newer evidence supports as EC up to 120h

— Antiemetic (ondansetron) recommended with oral EC

— Ceftriaxone 500 mg IM ×1 (1 g if ≥150 kg) — gonorrhea

— Doxycycline 100 mg PO BID ×7 days — chlamydia (azithromycin 1 g if pregnant or adherence concerns)

— Metronidazole 500 mg PO BID ×7 days — trichomonas/BV

— Preferred: Tenofovir disoproxil fumarate (TDF) 300 mg + emtricitabine (FTC) 200 mg PO daily + dolutegravir 50 mg PO daily (or raltegravir 400 mg BID)

— Alternatives: TAF/FTC + DTG; bictegravir-based regimens increasingly used

— Baseline HIV test, renal function, hepatitis serologies before starting

— Counsel on side effects (GI, headache), adherence, follow-up at 4–6 weeks and 3 months

— Unvaccinated/unknown → HBV vaccine series + HBIG (if source HBsAg+ or high risk)

— Vaccinated with documented response → no action

Emergency contraception (EC) — offer to all patients with childbearing capacity, negative baseline β-hCG:

STI prophylaxis (CDC 2021 guideline):

HIV post-exposure prophylaxis (PEP) — start within 72 hours, ideally <2 hours; 28-day course:

Hepatitis B prophylaxis:

HPV vaccine — offer per ACIP schedule (ages 9–45)

Tetanus — Tdap if wound and >5 years since last dose

Symptomatic: Ondansetron, NSAIDs/acetaminophen; avoid benzodiazepines routinely (risk in trauma-related insomnia, substance use) — short course only if severe acute distress and no contraindication.

Board pearl: PEP, EC, and STI prophylaxis are all started in the ED, not deferred to outpatient. A "starter pack" of PEP (3–7 days) bridges to ID/PrEP clinic follow-up.

Step 3 management: Always document the offer of each prophylaxis — and the patient's decision — even if declined.

Procedures / Revascularization / Invasive Management (or expanded pharmacology if non-procedural)

— Wound care: Irrigate and close lacerations per standard ED practice; document size, depth, location with photos before repair

— Pelvic exam with speculum — only as needed for evidence collection and injury assessment; smallest comfortable speculum, generous lubrication (water-based; avoid silicone if DNA collection)

— Anoscopy if rectal bleeding, severe pain, or suspected internal injury

— Foley catheter only if urinary retention, severe perineal trauma, or surgical need — avoid routine placement (re-traumatizing)

— Most effective EC method

— Requires trained provider; can be placed in ED or rapid referral

— Contraindications: active PID, pregnancy, uterine anomaly, copper allergy, Wilson disease

— Counsel that ongoing contraception is provided for 10–12 years

— Airway assessment paramount — low threshold for early intubation if expanding hematoma, stridor, or progressive edema

— CTA neck findings of dissection → vascular surgery consult, antiplatelet or anticoagulation per protocol

— Laryngeal fracture → ENT consult, possible surgical repair

— GHB intoxication → supportive (airway, monitoring); resolves within hours; flumazenil not indicated

— Benzodiazepine intoxication → supportive; avoid flumazenil (seizure risk in chronic users)

— Doxycycline + antacids/iron/calcium → separate by 2 hours

— Dolutegravir + polyvalent cations → space dosing; also caution in early pregnancy (small NTD signal — discuss alternatives if pregnancy planned)

— Ulipristal delays ovulation; do not co-administer with hormonal contraception within 5 days (mutual interference) — restart hormonal contraception 5 days after ulipristal

Procedural considerations in acute sexual assault care:

Copper IUD placement for EC:

Strangulation injury management:

Toxicology-specific care:

Expanded pharmacology nuances:

CCS pearl: On a CCS strangulation case, the high-yield orders are CTA neck, ENT consult, airway monitoring (admit telemetry/step-down), and antiplatelet therapy for confirmed dissection — missing the CTA is a classic deduction.

Board pearl: Copper IUD is the most effective form of EC and is unaffected by BMI — strongly consider in patients with obesity where oral EC efficacy drops.

Special Populations — Elderly and Renal/Hepatic Impairment

— Estimated <5% of cases reported; perpetrators often caregivers or institutional staff

— Presentations: unexplained genital injury/bleeding, new STI, recurrent UTI, sudden behavior change, fear of specific caregiver, poor hygiene

— Cognitive impairment complicates consent assessment — lack of capacity to consent = assault even without overt force

— Mandatory reporting to Adult Protective Services (APS) in all 50 states for vulnerable adults

— Document patient's ability to understand sexual activity, voluntariness, and consequences

— Dementia, delirium, severe intellectual disability typically preclude consent

— Capacity is decision-specific and may fluctuate

— Atrophic vaginal/vulvar tissue more prone to laceration — injuries may be more visible but also confused with age-related changes

— Skin fragility → bruising patterns harder to date; obtain photodocumentation

— Pre-existing incontinence, prolapse may obscure findings

— HIV PEP renal dosing: TDF requires CrCl ≥60; for CrCl 30–59, dose-adjust TDF or switch to TAF/FTC (preferred in CKD); avoid TDF if CrCl <30

— Doxycycline — no renal/hepatic adjustment needed (good choice in CKD)

— Ceftriaxone — no dose adjustment for renal impairment

— Metronidazole — reduce dose in severe hepatic impairment

— Levonorgestrel/ulipristal — caution in severe hepatic impairment; ulipristal not studied

— Dolutegravir + metformin → increases metformin levels (monitor)

— Doxycycline + warfarin → potentiates INR (monitor closely)

— Ondansetron + QT-prolonging meds → ECG before dosing

Elder sexual abuse — under-recognized:

Capacity assessment:

Physical exam considerations in elderly:

Pharmacologic adjustments:

Drug interactions common in elderly polypharmacy:

Step 3 management: For elder or dependent-adult sexual assault, the workflow is (1) medical care + forensic kit, (2) APS report (mandatory), (3) law enforcement notification per state law, (4) safe disposition — do NOT discharge back to suspected perpetrator's care. Engage social work and case management early.

Board pearl: A patient who "consented" but lacks capacity has been assaulted. Document capacity findings clearly; this is the linchpin of the legal case.

Special Populations — Pregnancy, Pediatrics, and Other Demographic Subgroups

— Sexual assault during pregnancy strongly associated with intimate partner violence; screen for IPV

— EC not applicable if already pregnant; confirm with β-hCG

— Fetal monitoring if ≥20 weeks gestation and any abdominal trauma; consider Kleihauer-Betke if Rh-negative

— Anti-D immunoglobulin for Rh-negative patients with abdominal trauma

— STI prophylaxis: azithromycin 1 g (instead of doxycycline) for chlamydia; ceftriaxone and metronidazole safe

— HIV PEP: continue standard regimen; dolutegravir now considered safe throughout pregnancy (NTD signal not confirmed in later data)

— OB consult; placental abruption risk if blunt trauma

— Mandatory reporting to CPS in all 50 states for any suspected child sexual abuse — clinical suspicion alone triggers report, not proof

— Refer to child abuse pediatrician / Child Advocacy Center when available — minimizes repeat interviews, expert forensic exam

— Acute (<72–120h) → forensic kit + prophylaxis; non-acute → focus on medical, psychological, safety

— Anogenital exam typically normal even with confirmed abuse — never use normal exam to refute history

— Adolescents: most jurisdictions allow minors to consent to STI testing, EC, and confidential care without parental consent — know state laws

— STI prophylaxis dosing pediatric: ceftriaxone 500 mg IM if ≥45 kg; weight-based if smaller; doxycycline only if ≥8 years and ≥45 kg (otherwise azithromycin)

— Substantially underreported; often delayed presentation

— Anal/oral exposure most common; assess for rectal trauma

— Same prophylaxis principles (no EC needed)

— Address shame, stigma, sexuality concerns explicitly

— Use chosen name/pronouns; do not assume anatomy or partners

— Increased baseline rates of sexual violence, especially trans women

— Higher victimization rates; perpetrators often caregivers

— Communication accommodations (interpreter, AAC device); never use family as interpreter for assault disclosure

Pregnant patients:

Pediatric/adolescent patients:

Male patients:

LGBTQ+ patients:

Patients with disabilities (physical, cognitive, sensory):

Board pearl: In a pediatric case, the report to CPS happens before discharge — not "we'll think about it." The clinician's threshold is reasonable suspicion, not certainty.

Complications and Adverse Outcomes

— Genital/anorectal injury with hemorrhage, infection, rectovaginal fistula (rare)

— Strangulation sequelae: carotid/vertebral dissection, stroke (may be delayed days–weeks), anoxic brain injury, laryngeal fracture, miscarriage

— Pregnancy from assault — ~5% of reproductive-age assaults

— STI acquisition: gonorrhea, chlamydia, trichomonas, syphilis, HIV, HBV, HCV, HPV, HSV

— HIV seroconversion: ~0.1–3% per exposure depending on type; markedly reduced by PEP

— Chronic pelvic pain, dyspareunia, vulvodynia

— Recurrent UTI, irritable bowel syndrome, fibromyalgia (functional somatic overlap)

— HPV → cervical/anal dysplasia; long-term cancer screening implications

— Chronic hepatitis B or C if not prevented

— Acute stress disorder (≤1 month) → PTSD (>1 month) develops in 30–50% of survivors

— Major depression, suicidality, panic disorder, substance use disorder

— Self-harm; suicide attempts elevated 4–10× baseline

— Dissociative symptoms, sleep disturbance, nightmares, flashbacks

— Sexual dysfunction, fear of intimacy

— Job loss, housing instability, relationship dissolution

— Re-traumatization through legal proceedings

— Stigma, victim-blaming, particularly in close-knit communities

— Re-traumatization from repeated histories, invasive exams without consent, dismissive providers

— Missed strangulation injuries → delayed stroke

— Inadequate PEP counseling → poor adherence → seroconversion

— Loss of evidence due to improper collection/storage

— Premature disposition to unsafe environment

Acute medical complications:

Delayed/subacute medical:

Mental health sequelae — the dominant long-term morbidity:

Social complications:

Iatrogenic harms to anticipate and prevent:

Key distinction: Acute stress disorder vs PTSD — same symptom clusters (intrusion, avoidance, negative cognition, hyperarousal), but ASD = symptoms 3 days to 1 month; PTSD = >1 month. Early intervention with trauma-focused CBT reduces PTSD progression.

Board pearl: Suicide risk peaks in the first 2 weeks post-assault and again around anniversary dates and legal proceedings — proactive follow-up at these intervals saves lives.

When to Escalate Care — ICU, Consult, or Inpatient Triage

— Strangulation with LOC, persistent neuro symptoms, or imaging-confirmed vascular injury → step-down/ICU for monitoring + anticoagulation

— Hemodynamic instability from trauma or hemorrhage

— Severe overdose/intoxication requiring airway support

— Major surgical injury (laparotomy, complex repair)

— Severe DFSA with prolonged altered mental status

— Active suicidal ideation with plan/intent

— Inability to maintain safety (intoxication, severe dissociation, psychosis)

— No safe disposition

— Voluntary admission preferred; involuntary hold per state criteria if imminent danger

— SANE/SAFE nurse — forensic exam (first call when available)

— OB/GYN — pregnancy complications, IUD placement, complex genital injury

— Trauma surgery — significant blunt/penetrating trauma

— ENT — laryngeal injury, strangulation with airway concern

— Vascular surgery/neurology — carotid/vertebral dissection

— Infectious disease — complex PEP decisions, immunocompromised host

— Pediatrics / child abuse pediatrician — minors

— Psychiatry — suicidality, acute psychosis

— Social work / victim advocate — safety planning, resources, hotline (RAINN 1-800-656-HOPE)

— Law enforcement — only with patient consent (adult, capable); mandatory for minors and vulnerable adults

Most sexual assault patients are managed and discharged from the ED. Admission is driven by injury severity, mental health acuity, or psychosocial unsafety — not the assault itself.

ICU/admission criteria — medical:

Psychiatric admission criteria:

Consults to consider:

CCS pearl: Even in an outpatient/ED CCS case that ends in discharge, you should order "social work consult" and "victim advocate" — these are graded as core care components. Schedule follow-up in 3–5 days with primary care or specialty clinic for PEP tolerability and mental health check-in.

Step 3 management: Never discharge a survivor to an unsafe environment. If the perpetrator is in the home, engage social work for emergency shelter (DV shelters, hotel vouchers) before signing discharge orders.

Key Differentials — Same-Category Causes

— Most common type of sexual assault; perpetrator is current/former partner

— Frequently coexists with physical IPV, financial abuse, coercive control

— Patients less likely to identify as "assault" — use specific behavioral questions

— Mandates IPV-specific safety planning, lethality assessment (HARK, Danger Assessment)

— Strangulation history is a major lethality predictor (8× increased risk of homicide)

— Voluntary or involuntary intoxication

— Patient may have fragmented or absent memory

— Toxicology windows short — collect early

— Belief of patient should not be diminished by intoxication

— Distinct legal definitions; mandatory CPS reporting

— Often chronic, involves grooming, not single event

— Refer to Child Advocacy Center

— Capacity-based determination

— Mandatory APS reporting

— Red flags: scripted history, accompanied by controlling individual, tattoos/branding, no ID, multiple ED visits, STI/pregnancy in young patient

— National Human Trafficking Hotline: 1-888-373-7888

— Engage trafficking-specific resources; offer private interview away from accompanying person

— Below age of consent (varies by state, typically 16–18)

— Mandatory report regardless of "consent"

— Romeo-and-Juliet exceptions in some states

— Inmates, patients in psychiatric facilities, military

— PREA (Prison Rape Elimination Act) protocols; military SAFE protocols (Restricted vs Unrestricted reporting)

Within "non-consensual or coerced sexual contact," consider distinct entities that share clinical territory but have different reporting, management, and forensic implications:

Intimate partner sexual violence (IPSV):

Drug-facilitated sexual assault (DFSA):

Child sexual abuse:

Elder/vulnerable adult sexual abuse:

Human trafficking with sexual exploitation:

Statutory sexual contact:

Institutional/custodial assault:

Key distinction: All of the above are sexual assault — categorization affects reporting pathway and resources, not whether the patient deserves the full medical/forensic care bundle. Treat first, categorize for documentation and reporting.

Board pearl: A young patient with recurrent STIs, multiple pregnancies, signs of branding, and a controlling companion should trigger human trafficking screening — separate the patient from the companion to interview.

Key Differentials — Other-Category Causes

— Posterior fourchette tears, friction abrasions can occur with consensual intercourse

— Injury alone does not establish non-consent; history is paramount

— Document objectively; do not editorialize

— Straddle injury (especially pediatric — bicycle, playground)

— Obstetric trauma

— Foreign body insertion (psychiatric, accidental)

— Sexual practices involving objects/BDSM (consensual)

— Vulvovaginitis, lichen sclerosus, atrophic vaginitis

— Postcoital bleeding from cervical polyp/cancer

— Hemorrhoids, anal fissure from constipation

— Urethral prolapse (pediatric, postmenopausal)

— Mongolian spots (pediatric)

— Coining/cupping (cultural healing practices) — document without prejudice

— Coagulopathies (ITP, hemophilia, anticoagulant use)

— Henoch-Schönlein purpura, leukemia

— Conversion disorder with pseudoseizures or memory gaps

— False memory in dissociative states

— Acute psychosis with sexual delusions

— These rarely fully account for a complete clinical picture — err on the side of believing and providing care

— Voluntary intoxication with amnesia from alcohol or polysubstance

— Patient genuinely may not know — still warrants evaluation for assault given vulnerability during blackout

— Extremely rare; never the initial assumption

— Beware diagnostic anchoring; never refuse care based on suspicion of fabrication

Conditions that may mimic, coexist with, or be misattributed to sexual assault — each requires its own workup:

Consensual sexual activity with injury:

Non-sexual perineal/genital trauma:

Spontaneous medical conditions presenting as bleeding/discharge:

Dermatologic mimics of bruising:

Psychiatric mimics:

Substance intoxication without assault:

Munchausen/factitious disorder:

Step 3 management: When the history is ambiguous (e.g., DFSA with amnesia, intoxication, conflicting accounts), the correct action is to provide full evaluation, prophylaxis, and forensic collection — withholding care for "uncertainty" is malpractice. The forensic and legal system, not the ED clinician, adjudicates what happened.

Board pearl: Believe the patient, treat the patient, document objectively. That is the entire framework for handling ambiguous presentations.

Secondary Prevention / Discharge Medications / Long-Term Plan

— EC (levonorgestrel or ulipristal) — given in ED, single dose

— STI prophylaxis: Doxycycline 100 mg BID ×7 days (or azithromycin 1 g ×1 if pregnancy/adherence); ceftriaxone already given IM; metronidazole 500 mg BID ×7 days

— HIV PEP starter pack (3–28 days depending on local supply) — TDF/FTC + dolutegravir; arrange ID follow-up within 1 week

— HBV vaccine — series initiation; second dose at 1 month, third at 6 months

— HPV vaccine initiation if eligible

— Tdap if indicated

— Antiemetic for PEP nausea (ondansetron PRN)

— Sleep: Trazodone or hydroxyzine preferred over benzodiazepines

— Medication purposes, schedules, side effects

— Symptoms requiring return: worsening pain, fever, vaginal/rectal bleeding, suicidal thoughts, PEP side effects (rash, jaundice, severe GI)

— Follow-up appointments scheduled before discharge when possible

— Crisis line: RAINN 1-800-656-HOPE, local rape crisis center

— 1–2 weeks: Mental health check-in, PEP tolerability, wound recheck

— 4–6 weeks: Repeat STI testing (NAAT GC/CT), pregnancy test, repeat HIV (4th-gen), syphilis RPR

— 3 months: Repeat HIV, HCV

— 6 months: Final HIV, HCV, HBV testing

— Annual: Cervical cancer screening per USPSTF; HPV-related surveillance

— Establish primary care relationship; trauma-informed provider

— Mental health: trauma-focused CBT, EMDR, prolonged exposure therapy

— SSRIs (sertraline, paroxetine) FDA-approved for PTSD; first-line pharmacotherapy

— Substance use disorder screening and treatment

— Reproductive health: ongoing contraception planning, PrEP consideration if ongoing risk

Discharge medication checklist:

Written discharge instructions in patient's preferred language:

Follow-up schedule:

Long-term prevention/health maintenance:

Board pearl: HIV testing follow-up at 4–6 weeks, 3 months, and 6 months is the standard schedule — memorize. With 4th-generation antigen/antibody testing, 4 months is often considered conclusive.

Step 3 management: Transition HIV PEP patients to a PrEP discussion at the 28-day completion visit if ongoing exposure risk exists — seamless prevention continuum is the modern standard.

Follow-Up, Monitoring Parameters, and Rehab/Counseling

— 48–72 hours: Phone or in-person check by victim advocate or SANE follow-up program

— 1 week: PEP tolerance, lab review (baseline HIV/HBV/HCV/syphilis), mental health screen (PHQ-9, PCL-5)

— 2 weeks: Repeat mental health screen — suicide risk peak window

— 4–6 weeks: Repeat STI NAAT (gonorrhea, chlamydia, trichomonas), β-hCG, HIV Ag/Ab, RPR

— 3 months: HIV, HCV, RPR

— 6 months: HIV (if HCV+ or high-risk source), HCV RNA, HBV serologies

— 12 months: HPV-related screening as appropriate

— Baseline + 2-week + 4-week: CBC, BMP (renal function), LFTs

— Adherence counseling at each visit — completion rates only ~40% without support

— Side effect management: nausea (ondansetron), fatigue, headache, insomnia

— Trauma-focused CBT is first-line psychotherapy (highest evidence for PTSD)

— Other evidence-based: prolonged exposure (PE), cognitive processing therapy (CPT), EMDR

— Pharmacotherapy: SSRIs (sertraline, paroxetine FDA-approved), SNRIs (venlafaxine) — start low, titrate; avoid benzodiazepines for PTSD (worsens long-term outcomes)

— Prazosin for trauma-related nightmares

— Avoid debriefing (single-session critical incident debriefing) — may worsen outcomes

— Pregnancy test at 4–6 weeks even with EC use (EC failure rate 1–3%)

— Discuss ongoing contraception, reproductive plans

— Discuss options if pregnancy results from assault — neutral, comprehensive counseling

— Clinical reassessment at 1 week and 1 month for delayed vascular/neurologic symptoms

— Repeat imaging only if symptoms develop

— Pelvic floor physical therapy for chronic pelvic pain/dyspareunia

— Sleep hygiene, exercise, nutrition counseling

— Peer support groups (RAINN, local rape crisis centers)

Structured follow-up cadence (Step 3 favors knowing the specific intervals):

PEP-specific monitoring:

Mental health follow-up:

Reproductive health monitoring:

Strangulation follow-up:

Rehabilitation considerations:

Board pearl: Avoid benzodiazepines for acute or chronic PTSD — they impair extinction learning, increase substance use disorder risk, and worsen long-term outcomes. SSRIs + trauma-focused therapy is the evidence-based pathway.

Step 3 management: Build a written longitudinal care plan at discharge — patients in crisis won't remember verbal instructions. Schedule appointments before they leave when possible.

Ethical, Legal, and Patient Safety Considerations

— Separate consent for (1) medical exam, (2) forensic evidence collection, (3) photography, (4) release of evidence to law enforcement, (5) prophylaxis medications

— Patient may consent to some and decline others

— May withdraw consent at any point; honor immediately

— Document consent process explicitly

— Adult competent survivors: In most US states, reporting to law enforcement is the patient's choice — clinician does NOT mandatorily report. Exceptions: some states require reporting of injuries from violent crime (gunshot, stab wounds); know your state.

— Minors: Mandatory CPS report for suspected child sexual abuse — clinical suspicion suffices; report before discharge

— Vulnerable adults (elderly, cognitively impaired, disabled): Mandatory APS report

— Active-duty military: Restricted vs Unrestricted reporting — Restricted preserves confidentiality while allowing care

— Human trafficking: Reporting varies by state and patient age

— Every transfer of evidence documented (who, when, where, signature)

— Break in chain of custody can render evidence inadmissible

— Store kit per institutional protocol; many states allow anonymous/"Jane Doe" kits stored without immediate law enforcement involvement, giving survivors time to decide

— Do NOT discuss case with family, partners, employers without patient consent

— Beware accompanying persons who may be perpetrators or controllers

— Interpreter services — never use family/companion

— Discharge to unsafe environment is a sentinel safety event. Coordinate with social work, DV shelters, hotel vouchers, family/friends before discharge.

— Communication to outpatient provider — share only what patient consents to share; some EMRs flag sensitive visits

— Prescribe enough PEP and follow-up scheduled to prevent care gaps

— Vicarious trauma is real — peer support, debrief programs, EAP

Informed consent — granular and ongoing:

Reporting obligations (highly testable):

Evidence handling and chain of custody:

Confidentiality:

Transition-of-care safety (Step 3 favorite):

Provider self-care:

Patient safety pearl: The most dangerous time for an IPV survivor is when they attempt to leave. Safety planning before disclosure of intention to leave, not after.

Board pearl: Mandatory reporting questions on Step 3: minors → CPS; vulnerable adults → APS; competent adults → patient's choice (in most states). Memorize this triad.

High-Yield Associations and Rapid-Fire Clinical Facts

— HIV PEP: ≤72 hours (start ASAP)

— Emergency contraception (levonorgestrel): ≤72h (declining efficacy)

— Ulipristal acetate: ≤120h

— Copper IUD: ≤120h (most effective EC)

— Forensic evidence kit: ≤120h (often, jurisdiction-dependent; up to 7 days in some)

— Hepatitis B PEP (HBIG): ≤7 days for sexual exposure

— Tetanus prophylaxis: ASAP if wound and last dose >5 years

Time windows — memorize cold:

Strangulation red flags: LOC, incontinence, voice change, dysphagia, petechiae, ligature mark, neuro deficit → CTA neck

Lethality predictors in IPV: prior strangulation, weapon threat, recent separation, perpetrator unemployment, victim pregnancy → 8× homicide risk

CDC STI prophylaxis 2021: Ceftriaxone 500 mg IM + doxycycline 100 mg BID ×7d + metronidazole 500 mg BID ×7d

HIV PEP 1st-line: TDF/FTC + dolutegravir ×28 days

Pediatric anogenital exam: most often normal even with confirmed abuse

Adult anogenital exam: normal in majority of penetrative assault cases

EC efficacy and BMI: Levonorgestrel less effective if BMI >30; ulipristal less effective if BMI >35; copper IUD efficacy unaffected by BMI

DFSA drugs and detection windows: Alcohol (hours), GHB (urine ~12h, blood ~6h), benzodiazepines (24–72h), ketamine (24–72h), THC (days–weeks)

Mandatory reporting triad: Minors → CPS; vulnerable adults → APS; competent adults → patient's choice

First-line PTSD pharmacotherapy: SSRIs (sertraline, paroxetine) — FDA-approved

PTSD therapy first-line: Trauma-focused CBT, prolonged exposure, cognitive processing therapy, EMDR

Avoid: Benzodiazepines for PTSD, single-session debriefing, flumazenil in DFSA

HIV follow-up testing: 4–6 weeks, 3 months, 6 months (4th-gen Ag/Ab)

Hotlines: RAINN 1-800-656-HOPE; National Human Trafficking 1-888-373-7888; National DV Hotline 1-800-799-SAFE

Board pearl: If the stem says "presenting at 96 hours," PEP is out of window, but EC (ulipristal/copper IUD), STI prophylaxis, HBV vaccine, and forensic kit are still in window. Read time stamps carefully.

Board Question Stem Patterns

→ Answer set: Ceftriaxone + doxycycline + metronidazole + EC (levonorgestrel or ulipristal) + HIV PEP (TDF/FTC + dolutegravir) + HBV vaccine + offer SANE exam + follow-up in 1 week. The wrong answer is "wait for STI results."

→ Best EC: Copper IUD (most effective, unaffected by BMI, within 120h window). Levonorgestrel less effective beyond 72h and with obesity. PEP not offered — outside 72h window. Still offer STI prophylaxis, HBV vaccine, forensic kit.

→ Next step: CTA of the neck. Admit for observation. The miss is discharging — delayed carotid dissection causes stroke days later.

→ First action: Mandatory report to CPS (before workup completion is fine — but the report must happen). Refer to Child Advocacy Center. Do NOT confront alleged perpetrator. Do NOT discharge to same household.

→ Mandatory APS report. Forensic exam with capacity documentation. Separate from suspected caregiver. Engage social work, ombudsman.

→ Provide full medical and forensic care anyway (anonymous kit option in many states). The patient's autonomy regarding law enforcement is preserved. Wrong answer: "refuse forensic exam unless reporting to police."

→ Continue PEP, add ondansetron, check renal function/CBC/LFTs, repeat HIV at 4–6 weeks. Do not stop PEP for nausea alone.

→ Psychiatric evaluation/admission, suicide risk assessment, start SSRI (sertraline), trauma-focused therapy referral. Do NOT prescribe benzodiazepines for PTSD.

Classic Step 3 stems and the move that scores:

Stem 1: 24F presents 36 hours after acquaintance rape. Anxious, exam unremarkable, β-hCG negative.

Stem 2: 32F presents 96 hours post-assault, BMI 38.

Stem 3: Assault with strangulation; transient LOC, now alert with hoarse voice.

Stem 4: 14-year-old discloses assault by stepfather.

Stem 5: Nursing home resident with advanced dementia, new vaginal bleeding and bruising.

Stem 6: Patient declines police involvement but wants medical care.

Stem 7: Returns at 4 weeks on PEP, persistent nausea, otherwise tolerating.

Stem 8: Patient with active suicidal ideation 2 weeks post-assault.

Board pearl: Step 3 loves time-window discrimination (72h vs 120h vs 7 days) and mandatory reporting triggers (minor, vulnerable adult, weapon injury depending on state). When in doubt, default to "treat the patient now, document objectively, report when mandated, follow up early."

One-Line Recap

Sexual assault care is a parallel-tracked ED encounter in which medical stabilization, time-sensitive prophylaxis, forensic evidence preservation, and trauma-informed psychosocial support must all happen together — never sequentially.

— Medical: Stabilize trauma, assess strangulation (CTA neck if any neuro symptoms), treat injuries

— Forensic: SANE-led kit within ~120 hours, chain of custody, patient consent at every step

— Prevention: EC (levonorgestrel/ulipristal/copper IUD per window + BMI), STI prophylaxis (ceftriaxone + doxycycline + metronidazole), HIV PEP ×28d if ≤72h (TDF/FTC + dolutegravir), HBV vaccine ± HBIG, HPV vaccine, Tdap

The three-track framework:

The four time windows to memorize: HIV PEP ≤72h; levonorgestrel EC ≤72h; ulipristal/copper IUD/forensic kit ≤120h; HBIG ≤7 days

The reporting triad: Minors → CPS (mandatory); vulnerable adults → APS (mandatory); competent adults → patient's choice (with some state exceptions for violent-crime injuries)

The discharge bundle: Medications in hand, follow-up scheduled at 1 week / 4–6 weeks / 3 months / 6 months, safe disposition confirmed (DV shelter if needed), mental health and victim advocate engaged, written instructions, hotline numbers (RAINN 1-800-656-HOPE), trauma-focused therapy referral, SSRI consideration for emerging PTSD — and never, ever benzodiazepines as primary PTSD pharmacotherapy

Final board mantra: Believe the patient, treat the patient, document objectively, report when mandated, follow up early, and never discharge to an unsafe environment. That single sentence reliably solves the Step 3 sexual-assault vignette regardless of which clinical or ethical wrinkle is added.