Sexual Assault/Domestic

Violence
a, b
Ruth E.H. Yemane, MD *, Nancy Sokkary, MD

KEYWORDS
 Intimate partner violence  Sexual assault  Child sexual assault  Forensic

KEY POINTS
 Sexual assault and intimate partner violence (IPV) are prevalent in the United States.
 Pregnant women and women of color are particularly high-risk populations for sexual as-
sault and IPV.
 Systematic forensic evaluation and treatment of sexual assault and IPV victims are impor-
tant aspects of care for these patients.

INTRODUCTION

Sexual assault and intimate partner violence (IPV) affect millions of women each year
in the United States.1 Although sexual assault and IPV occur in people of all ages,
races, and socioeconomic backgrounds, women of color are disproportionately
impacted.1 Furthermore, pregnant women are vulnerable to physical violence, with
homicide as one of the leading causes of maternal mortality.2 The health care costs
of sexual assault and IPV are significant, and sequalae include financial, medical,
and psychological harm. Assessment and treatment by an obstetrician and gynecol-
ogist may be essential in an acute care setting for victims of sexual assault and IPV.
Appropriate, timely intervention may also prevent future negative outcomes associ-
ated with this violence.

Background
Definitions
The Centers for Disease Control and Prevention (CDC) defines intimate partner
violence (IPV), commonly known as domestic violence, as “abuse or aggression
that occurs in a romantic relationship.”3 IPV can be episodic or chronic in nature,
and it includes physical violence, stalking, sexual violence, and psychological

a
University of Wisconsin-Madison, West Clinic, 451 Junction Road, Madison, WI 53717, USA;
b
Emory University School of Medicine, Children’s Healthcare of Atlanta, 1400 Tully Drive,
Atlanta GA 30329, USA
* Corresponding author.
E-mail address: ryemane@[Link]

Obstet Gynecol Clin N Am 49 (2022) 581–590

[Link] [Link]
0889-8545/22/ª 2022 Elsevier Inc. All rights reserved.
582 Yemane & Sokkary

aggression. Sexual violence is defined as a “sexual act that is committed or attempted

by another person without freely given consent of the victim or against someone who
is unable to consent or refuse.”4
The National Intimate Partner and Sexual Violence Survey (NISVS) reports more than
one-third of women in the United States have been victims of rape, physical violence,
and/or stalking by an intimate partner in their lifetime, which translates into 42.4 million
women.1 NISVS further reports 1 in 3 women has experienced physical violence; 1 in 10
women has been raped by an intimate partner, and half of women have experienced
sexual violence victimization at some time in their lives.3 There are also racial disparities
associated with IPV and sexual assault. Analysis of homicide data by the National Vio-
lent Death Reporting System of nearly 10,000 women aged 18 and older demonstrated
non-Hispanic black and American Indian/Alaska Native women experience the highest
rates of homicide (4.4 and 4.3, per 100,000 population, respectively).5 Furthermore,
55.3% of all reported homicides were IPV-related, and 11.2% of these victims were
subject to some form of violence in the month before their deaths. In addition, evaluation
of IPV among pregnant women showed increased risk for homicide in pregnancy was
greatest in younger women and non-Hispanic black women.2
IPV in pregnancy has both detrimental maternal and neonatal effects. Women expe-
riencing IPV during pregnancy have increased risk of insufficient prenatal care, poor
weight gain, higher rates of smoking and alcohol abuse, and substance abuse.6
They also incur higher rates of intrapartum and postpartum depression.6 Pregnant
women who sustained physical assault had higher rates of prematurity, maternal
death, fetal death, and uterine rupture compared with women who did not experience
assault.7 Recent findings further revealed that homicide is the leading cause of death
during pregnancy and the postpartum period in the United States.2 Most pregnancy-
associated homicides occurred at home, implying IPV may have contributed to these
horrific maternal outcomes.

Health Care Costs/Public Health Impact

The direct financial and tangible impacts of domestic violence and sexual assault in
the United States are significant. The National Center for Injury Prevention and Control
reports that intimate partner rape, stalking, and physical assault cost more than $5.8
billion annually and nearly $4.1 billion in direct medical and mental health services.8
IPV also costs nearly $1 billion in lost productivity and nearly $1 billion in lost lifetime
earnings for victims of nonfatal IPV.8 Overall, health care is the largest portion of IPV-
related costs.

Screening
Health care providers have a unique position to both assess and help treat patients at
risk of IPV. For this reason, IPV screening should be done routinely. The US Preventa-
tive Services Task Force recommends clinicians screen for IPV in all women of repro-
ductive age.9 Although well-woman examinations, prenatal care visits, and
postpartum visits are all opportunities for obstetrician-gynecologist providers to
screen patients in routine settings, it should also be done in urgent and acute settings,
such as the emergency department or obstetric triage units.
Furthermore, the nature of the obstetrician-gynecologist provider-patient relation-
ship presents several opportunities when IPV or sexual assault concerns may be
addressed. Chronic pelvic pain, sexual dysfunction, recurrent sexually transmitted in-
fections (STIs) or testing for STIs, depression, substance abuse, multiple pregnancy
tests in a patient not desiring pregnancy, and fear in discussing condoms with a part-
ner, are all clinical scenarios that may reflect IPV. The American College of
 Sexual Assault/Domestic Violence 583

Obstetricians and Gynecologists (ACOG) advises screening patients in a private, safe

setting using clear communication tools. Introducing the topic with a framing state-
ment can be very useful to smoothly transition into this subject and avoid alarming
the patient. ACOG uses the following as an example, “We’ve started talking to all of
our patients about safe and healthy relationships because it can have such a large
impact on your health.”10 Take-home materials, including printed resources of local
services and national hotlines, should be openly available in the clinical setting and pri-
vately available, such as in clinic and emergency room restrooms. It is imperative to
avoid assumptions and biased language. How obstetrician-gynecologist providers
communicate with patients helps to build a trusting relationship and create a physi-
cally and psychologically safe space that is vital in caring for patients with a history
of trauma.

Evaluation
It is imperative to provide timely, compassionate, and comprehensive care for victims
of IPV and sexual assault. A coordinated, multidisciplinary approach to treatment is
important and very well may include obstetrician-gynecologist providers. A Sexual As-
sault Nurse Examiner (SANE), also known as a forensic nurse or Sexual Assault
Forensic Examiner (SAFE), is a provider who has completed training in forensic med-
ical care for victims of sexual assault. Ideally, a SANE collects a forensic history and
performs a medical forensic examination after other health care providers have eval-
uated and stabilized an assault victim in an acute care setting. The historical and phys-
ical data collected by a SANE have proven to be more comprehensive and effective
than a non-SANE provider.11 If the acute care setting does not have immediate access
to a SANE or SAFE, it is advisable to create an order set or protocol to assure key as-
pects of evaluation and treatment are addressed.

History
A victim-centered approach ensuring informed consent, clear communication, confi-
dentiality, and immediate safety is imperative when it comes to history taking in this
situation. It is also important to attain as much accurate information regarding the
perpetration as possible. Important initial questions for victims of sexual assault
include “who, what, when, with what, and how.”11

Physical examination
A physical examination is ideally completed by a SANE provider, as this optimizes the
chances of performing the examination in a standardized fashion that avoids interrup-
tions, minimizes retraumatization of the victim, and collects findings for both medical
and legal purposes. Details of the examination are beyond the scope of this article;
however, in an emergent situation, a general physical examination should be per-
formed to assess any injuries that require immediate intervention. This may include
genital examination, speculum, or rectal examination, depending on location and
severity of injuries. Providers interested in learning more details of the physical exam-
ination may reference “A National Protocol for Sexual Assault Medical Forensic Exam-
inations” or “Evaluation and Management of Female Sexual Assault Victims.”11,12
Pregnant patients who are victims of direct abdominal trauma as a result of IPV or
sexual assault require additional testing and often multidisciplinary support depending
on severity of injuries and hemodynamic stability of the patient. These patients are at
risk for placental abruption, preterm birth, premature rupture of membranes, uterine
rupture, amniotic fluid embolus, and pelvic fracture.13 Once a pregnant patient has
been stabilized, a secondary survey to assess for fetal well-being can be performed
584 Yemane & Sokkary

with fetal Doppler, bedside ultrasound, or continuous external fetal monitoring

depending on the gestational age. If a patient is presenting with vaginal bleeding or
leaking fluid, a sterile speculum examination should be performed. Studies have
demonstrated that uterine contractions are the single most important predictor of
placental abruption, so a tocometer should be placed to assess uterine activity if
appropriate for gestational age.13 Bedside ultrasound can quickly assess for fetal
heart tones, gestational age, amniotic fluid index, placental location, and any evidence
of placental separation.
Laboratory assessment
Several routine laboratory tests may be initiated by any provider or facility without ac-
cess to a SANE provider. Following a sexual assault, testing should include screening
for STIs (Table 1).
Additional serum laboratory tests to consider if the victim is pregnant include a com-
plete blood count, type and screen, fibrinogen, fetal maternal hemorrhage screen with
flow cytometry, serum creatinine, and coagulation profile.12 Rh D immune globulin is
indicated in Rh-negative pregnant patients who have direct abdominal trauma, with
dosage dependent on results of the fetal-maternal hemorrhage screen.12 Extended
monitoring is warranted if uterine contractions, uterine tenderness, vaginal bleeding,
rupture of membranes, nonreassuring fetal heart rate patterns, or more extensive
maternal trauma is present.”13
Treatment
STI exposure risk and risk of pregnancy may be significant concerns for sexual assault
victims. Access to appropriate evaluation and treatment should be made available.
The CDC reports the most common infections found on forensic examinations are
chlamydia, gonorrhea, trichomonas, and bacterial vaginosis.14 Although the source
of these infections may remain unknown, a forensic examination is an opportunity
to screen and treat patients who are victims of sexual assault.
CDC 2021 STI treatment guidelines advise the following15:
Empiric treatment for chlamydia and gonorrhea should be offered, with consider-
ation for treatment of trichomonas and provision of emergency contraception. Postex-
posure hepatitis B and human papilloma virus (HPV) vaccination should be offered. If a
victim is fully vaccinated, no additional treatment is necessary. If the perpetrator is
known hepatitis B positive, unvaccinated victims should receive hepatitis B immuno-
globulin and begin hepatitis B vaccination series. HPV vaccination should be offered
to victims aged 9 to 26 years who have not been vaccinated or incompletely

Table 1
Post-sexual assault STI Evaluation

Recommended Source Site

NAAT for [Link] and [Link] Site of assault or attempted assault
NAAT for [Link] Urine or vaginal sample
Wet prep for bacterial vaginosis and candidiasis Vaginal
HIV Serum
HBsAg Serum
RPR Serum

Per the CDC “2021 STI Treatment Guidelines-Sexual Assault, Abuse, and STIs”
Abbreviation: HBsAg, Hepatitis B surface Antigen; HIV, Human Immunodeficiency Virus; NAAT,
Nucleic Acid Amplification Test; RPR, Rapid Plasma Reagin.
 Sexual Assault/Domestic Violence 585

vaccinated. The first dose should be administered at the time of initial examination,
then routine dose scheduling should be followed thereafter (Table 2).
Recommendations for HIV postexposure prophylaxis (PEP) should be individual-
ized. Per 2021 CDC STI Treatment Guidelines, a 3- to 7-day starter pack or 28-day
course of zidovudine can significantly reduce risk of acquiring HIV.14 If the patient
agrees to HIV testing, baseline testing should be performed within 72 hours of poten-
tial exposure. Factors to consider in determining if PEP is advisable include local
epidemiology of HIV, time elapsed since potential exposure, probability that perpe-
trator has HIV, and nature of exposure event. Furthermore, risks and benefits of
PEP should be addressed. Consider consulting with an HIV specialist if PEP is being
seriously considered. If PEP therapy is initiated, order laboratory tests to assess base-
line renal and hepatic function, including serum creatinine, aspartate aminotrans-
ferase, and alanine aminotransferase. For assistance with PEP-related decisions,
the National Clinicians Post Exposure Prophylaxis Hotline may be contacted (888-
448-4911).
The CDC advises follow-up examinations for STI testing, vaccination, and coun-
seling 1 to 2 weeks after a sexual assault, and repeat HIV and syphilis testing is
advised 6 weeks, 3 months, and 6 months after an assault, if initial screening was
negative.15
Risk of pregnancy may be a grave concern for victims of sexual assault. Pregnancy
testing (serum or urine pregnancy test) should be offered to all victims of reproductive
age after informed consent, per SANE guidelines; if initial pregnancy testing is nega-
tive, emergency contraception should be discussed.12 Emergency contraception op-
tions include copper intrauterine device, levonorgestrel tablets (plan B), or ulipristal
acetate. Levonorgestrel tablets may be prescribed up to 72 hours following assault,
and the copper IUD and ulipristal acetate are effective up to 120 hours after the as-
sault.16 It is also important to discuss efficacy, risks, benefits, and side effects of
each option with the patient. States may have conscience statutes to protect health
care providers with moral/religious objections to contraception. However, a provider
with these objections must still refer the patient to a prescriber or facility that offers
these services.12
Reporting
Per the 2013 National Protocol for Sexual Assault Medical Forensic Examinations,
“reporting the crime provides the criminal justice system with the opportunity to offer
immediate protection to victims, collect evidence from all crime scenes, investigate
cases, prosecute if there is sufficient evidence, and hold offenders accountable for
crimes committed.”12 However, victims must have autonomy to decide to report.

Table 2
Postsexual assault treatment

Recommended Consider
Doxycycline 100 mg po bid  7 d HBIG 5 mL IMa
Ceftriaxone 500 mg IM  1 Hepatitis B vaccine (routine scheduled)b
Metronidazole 500 mg po bid  7 d Human papilloma virus vaccine (routine schedule)b
Zidovudine po for 3–7 d
Copper intrauterine device, levonorgestrel tablets, or
ulipristal acetate
a
If victim not vaccinated and perpetrator suspected to be positive.
b
If victim unvaccinated.
586 Yemane & Sokkary

Risks and benefits of reporting should be discussed with the patient, including the op-
tion to report at a later time, recognizing this may make prosecution more challenging.

Child Sexual Assault

Background
Definition. Sexual assault in a minor, or child sexual assault (CSA), is defined as
attempted or completed contact or noncontact sexual interaction in an individual
who legally cannot give consent, is unprepared for developmentally, cannot compre-
hend, and/or that violates the law of society.17
The perpetrator of sexual assault in most cases of CSA is a relative or acquaintance.
In the emergency setting, a child may present as a result of trauma or injury attained
during sexual assault, or it may be disclosed to a health care provider during a visit for
another ailment.17,18
According to the US Department of Health and Human Services (DHHS), there are
more than 60,000 reported cases of child sexual abuse annually.19 However, this is
likely an underestimate, as 15% to 30% of girls are estimated to experience some
type of sexual abuse. Children with disabilities and developmental delay are at
increased risk of sexual assault and other forms of abuse.18,20,21

Screening
Several screening tools exist to evaluate for CSA, specifically in the emergency
department. Gynecologic evaluation should include confidential sexual abuse
screening, regardless of the setting. Approaching the topic in an objective and routine
manner that is incorporated into the greater social history assures that no biases play a
role in the patients who are screened. Children presenting with nonspecific symptoms
and signs should be questioned carefully and in a nonleading manner about any
stressors, including abuse, in their life.17 Introducing the subject as something that ap-
plies to all patients, similar to the approach as previously outlined for adults, is also
recommended. It is imperative to screen both the parent and the child in private.

Evaluation
In an acute care setting, sexual abuse examination facilities and victim advocates
should be alerted immediately upon presentation of a victim. Most institutions do
have existing protocols for these teams. The goal of evaluation in the acute setting
is to identify injuries, evaluate for suicidal ideation or human trafficking, screen for
or diagnose STIs, and reduce risk of pregnancy.22 Although it is recommended for
CSA evaluations to be performed at a center with expertise and familiarity with this
scope of practice, urgent or emergent evaluations are appropriate for the following sit-
uations: abuse that occurred within 72 to 96 hours, physical injuries that require treat-
ment, collection of obvious forensic evidence, or if the child is in imminent danger
either from the perpetrator or from self. If the victim’s situation does not meet any of
these criteria, then delay in evaluation until the patient can be seen at a specialized
center should be strongly considered.17,23
It is beyond the scope of this article to review in depth recommendations for Sexual
Assault Nurse Evaluations or forensic interviewing, but the following will outline key
points and recommendations. Please see “A National Protocol for Sexual Abuse Med-
ical Forensic Examinations Pediatric” for full details regarding evaluation of CSA
victims.12

History
A forensic interview is part of a comprehensive investigation and is performed by a
trained professional. It is imperative that the history be taken from the child in an
 Sexual Assault/Domestic Violence 587

unbiased fashion, giving both the caregiver and the child an opportunity to disclose
information in private and together, if appropriate.24
The history should address the chief complaint, injury, or report of sexual abuse and
include a basic medical and surgical history. When asking about the event or events in
question, it is important to illicit if the caregiver (or other responsible party) has any
concerns. When interviewing the child, it is advisable to collect information in a simple,
objective manner, while maintaining a safe and caring demeanor. It may be appro-
priate to ask the child if they know why they are there and what words they use to
describe their private parts. This should be followed by asking specific questions,
as addressed in the adult section, in reference to who, what, when, with what, and
how.11 In the emergent setting, it is important to evaluate for pain, bleeding, and ability
to void. A formal forensic interview will illicit where the assault took place, how many
times the victim has been assaulted, over what period of time, and details of the
manner of the assault. In the acute setting, it is important to know the details and
timing of the most recent event.17,24
Review of systems should include change in bowel or bladder habits, such as new-
onset enuresis or regression of potty training, change in sleep patterns or eating
behavior. Social history is critical to identify factors surrounding safety of the child,
including who they live with, caregivers, other support structures, school, and extra-
curricular activities.25

Physical examination
A routine physical examination should be performed in an acute setting to address
stability of the patients and assess for injuries requiring immediate attention. Repeat
pelvic examinations should be avoided, if possible, and performed by a provider
trained in SANE. An obstetrician-gynecologist may be called to perform an examina-
tion to assess for injury specific to the genital region. It is imperative to work with the
emergency room providers as well as anesthesia personnel to provide the safest and
most comfortable examination possible; sedation should be strongly considered. Ex-
amination should include inspection for vaginal discharge, bleeding, and odor.
Although vulvar condyloma and herpetic lesions in the anogenital region should war-
rant investigation for sexual assault in a minor, they are not diagnostic for sexual
abuse.14

Laboratory evaluation
Laboratory diagnosis of specific infections provides important evidence in the case of
CSA and is also critical for the evaluation and appropriate treatment of the victim. It is
imperative to have a uniform approach to test selection and collection technique that
considers patient age, gender, and anatomic location.
Laboratory testing is challenging in prepubertal victims because of the low preva-
lence and lack of thorough test validation in this age group.26 Routine laboratory
testing should include the same as those recommended for adults (see Table 1).
Nucleic acid amplification tests (NAAT) are the preferred tests given their superior
sensitivity and specificity; however, CSA assessments may require more than 1
NAAT and a culture. Most institutions with sexual assault evaluation teams have pro-
tocols in place, but it does present an additional level of complexity to the evaluation.26
Similar to adult victims, swabbing of various orifices (oral, genital, anal) should be
carefully considered. In patients who are postpubertal, pregnancy testing should be
performed, and possibly repeated in 2 to 4 weeks, depending on when the assault
occurred. Clinical specimens reviewed by the laboratory may also reveal sperm, which
would provide definitive forensic evidence of sexual assault.
588 Yemane & Sokkary

Reporting
DHHS Children’s Bureau considers certain persons “mandated reporters,” and they are
required to report suspected cases of child abuse and neglect to the appropriate
agency in their area. Mandated reporters are typically provided immunity from liability
with good-faith reporting. Circumstances in which a report should be placed, and in
most cases is mandatory, varies widely but certainly applies to any situation in which
child abuse or neglect is suspected. Information on reporting agencies in a specific re-
gion of the country can be found on the Child Welfare Information Gateway Web site.27
Treatment
Prophylactic treatment of postpubertal individuals is the same as that described for
adults (see above). For prepubertal victims, the incidence of STIs is very low so pro-
phylactic treatment is not recommended in this patient population unless there is
elevated concern based on history or specific symptoms. HIV PEP is generally well
tolerated in children but should only be performed after thorough evaluation of the
child’s risk and in consultation with a specialist in pediatric HIV cases. A repeat exam-
ination should be conducted 2 weeks after the most recent assault; diagnostic testing
can also be repeated at that time if initial assessment was negative. HIV, hepatitis B,
and syphilis serologic screening can be repeated again between 6 weeks and
3 months after the most recent assault.14
Outcomes
The morbidity of CSA invades far beyond physical injuries and trauma in childhood. A
comprehensive review and meta-analysis found a substantial association between
child sexual abuse, substance abuse, and posttraumatic stress disorder (PTSD).28
Several additional health, psychiatric, and social ailments have been associated
with victims of sexual assault.28
People who are victims of childhood sexual assault have higher risk of depression,
self-injurious behavior, and attempted suicide well into adulthood.18,28 There is also a
statistically significant increase in the likelihood of experiencing anxiety, eating disor-
ders, PTSD, and sleep disorders.21,29 There are also data that suggest that penetrative
trauma is linked to a higher risk of self-injurious behavior.30
CSA is also a risk factor for specific physical illnesses, including HIV and obesity.
The cause of this may be due to psychosocial issues, such as increased “risky
behavior,” resulting in more or riskier sexual acts and higher risk of HIV acquisition,
as well as disordered eating or depression leading to obesity.28

SUMMARY

IPV and sexual assault of a minor or adult are situations that every obstetrician and gy-
necologist will be exposed to in their career, both in outpatient clinics and in the emer-
gency care setting. As a provider, the obstetrician-gynecologist can elicit a sensitive
history, perform a thorough evaluation, and provide necessary therapy in a safe,
objective, and appropriate manner. Several useful protocols and guidelines have
been developed, in addition to specially trained personnel, to assist and consult
when dealing with IPV and sexual assault.11

CLINICS CARE POINTS

 Sexual assault and intimate partner violence can have devastating medical, psychological,
and financial effects on victims.
 Sexual Assault/Domestic Violence 589

 Obstetrician-gynecologists should screen all patients, regardless of age, for sexual assault,
including in emergency care settings.
 A multidisciplinary approach, including access to a Sexual Assault Nurse Examiner, can
improve care for victims of assault.
 There are routine, standardized laboratory tests and prophylactic medical therapies for
sexual assault victims, outlined by the Centers for Disease Control and Prevention.

National resources (number or Web sites for providers or victims)

[Link].
[Link].
National Sexual Assault Telephone Hotline, 1-800-656-4673.
National Clinicians Post Exposure Prophylaxis Hotline, 1-888-448-4911.

DISCLOSURE

The authors have no commercial or financial disclosures to report.

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