II. Epidemiology

  1. Rape lifetime Incidence: 1.4% of U.S. men (typically before at 25 years old)
    1. Contrast with rape lifetime Incidence of 18% in women
    2. However, lifetime Incidence of other sexual Violence is approximately 5% for both genders
  2. Perpetrators of male victim rape are also male in 80% of cases
    1. However females are more common perpetrators of other sexual Violence (e.g. made to penetrate, sexual coercion)
    2. Perpetrators are known to the victim in most cases (52% acquaintance, 29% intimate partner)
    3. More than one perpetrator is twice as common in the rape of male victims than femal victims
  3. Male victims tend to be less willing to report rape than females
    1. However, males are more likely to report rape by strangers, especially if injury was sustained
  4. Male victims are heterosexual in 68% of rapes

III. Risk Factors: Sexual Assault with Male Victims

  1. Jail or prison inmate (2-5% of male prison inmates, more than half by staff perpetrators)
  2. Institutionalized
  3. Homeless
  4. Transgender
  5. Physically disabled
  6. Cognitive Impairment
  7. Mental health patient
  8. College students (5-8% of male college students)
  9. Military personnel (up to 1.8% of active duty males)
  10. Gang members

IV. Presentations

  1. Intoxication
    1. Forced Alcohol consumption
    2. Date Rape Drug (e.g. Benzodiazepines, Diphenhydramine, Rohypnol, Gamma Hydroxybutyrate)
  2. Musculoskeletal or other non-sexual Trauma (e.g. Physical Restraint)
    1. Systemic injuries in 66% of patients
  3. Oral Trauma
    1. Oral penetration in 43% or patients
    2. Pharyngeal Gonorrhea is not uncommon after forced oral penetration
  4. Anal Trauma (esp. digital, fist or object penetration)
    1. Anal penetration in 67% of patients
    2. External effects
      1. Anal tears, fissures, bleeding, tenderness, or hematoma
    3. Internal effects (may require general surgery evaluation under anesthesia)
      1. Traumatic Proctitis
      2. Retained Foreign Body
      3. Anal sphincter disruption
      4. Rectal mucosal Laceration
      5. Rectosigmoid transmural perforation

V. Labs: Sexually Transmitted Infection

  1. Urine Samples (consider repeating at 2 week)
    1. Gonorrhea PCR
    2. Chlamydia PCR
    3. Pharyngeal Gonorrhea Culture
  2. Serology initially and at 6, 12 and 24 weeks
    1. Hepatitis B Surface Antigen and Hepatitis B core IgM
    2. RPR for Syphilis Testing
    3. HIV Test

VI. Management

  1. Same Rape Management approach as with Female Rape Victim
  2. Initial emergency department management
    1. Ensure patient safety
    2. Medical screening exam and evaluate for serious injury or complication
      1. Avoid destruction or alteration of physical evidence prior to SANE evaluation
      2. Manage serious and life threatening injuries via ATLS protocol
      3. Perform standard wound and Fracture care management
    3. Assess prophylactic medication indications (SANE will also make recommendations)
      1. See regimen below
  3. Forensic exam by Sexual Assault Nurse Examiner (SANE)
    1. Transfer may be needed to facility able to perform exam, if SANE provider not available at presenting hospital
    2. May be performed up to 5-7 days following assault (accuracy diminishes with time)
    3. Forensic evidence from oral or anal penetration collected within 24-36 hours (72 hours in children)
    4. Patients may consent or decline to each part of the evaluation (exam, photos, evidence collection)
    5. Up to 8 sterile saline swabs collect evidence from mouth, neck, Breast, nipple, penis, Scrotum, perineum and Rectum
      1. UV Light may be used to highlight additional evidence areas
      2. Saliva, semen and urine (as well as soap and lotion) fluoresce or glow under UV light
    6. Anoscopy
      1. Anal swabs are obtained at a point approximately 2 cm within the Rectum
      2. Toluidine Blue dye may be used to highlight Lacerations and tears near the anus
      3. More extensive evaluation and possible repair by general surgery under anesthesia may be needed
    7. Toxicology Screening
      1. Screen for substances used in Alcohol and Drug Facilitated Sexual Assault (ADFSA)
      2. Toxicology specimens may be obtained up to 96 hours after assault
  4. STD Prevention (perform all measures)
    1. Ceftriaxone 250 mg IM for 1 dose
    2. Azithromycin 1 g orally for 1 dose (or Doxycycline 100 mg twice daily for 7 days)
    3. Hepatitis B Vaccine (HepB Immunoglobulin is not recommended)
  5. Consider HIV Prophylaxis in high risk exposure
    1. See HIV Postexposure Prophylaxis
    2. Assess HIV risk in assailant
    3. Receptive anal intercourse has the highest HIV Transmission risk
    4. Consider contacting National Clinician's Post-exposure Prophylaxis hotline (PEPline) at 888-448-4911
    5. Follow-up required in 7 days if prophylaxis started
  6. Disposition
    1. Rape crisis center
    2. Consider mental health counseling (after initial follow-up)
      1. Mood Disorders and Alcohol Abuse are very common after rape

VIII. References

  1. Riviello (2017) Crit Dec Emerg Med 31(3): 3-10
  2. McLean (2013) Best Pract Res Clin Obstet Gynaecol 27(1): 39-46 [PubMed]

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