The Case

A 25-year-old male presents to the emergency department (ED) after being sexually assaulted. The patient reports no physical violence, but was at a party with some friends when he got separated from them. He had a few alcoholic drinks and later felt dizzy. The next thing he remembers is waking up in a bedroom with at least two other males, whom he did not recognize, standing over him, naked, and laughing. A few minutes after waking up, he was more alert and realized he was naked and had pain in his anus. His vital signs are normal. He was quiet and tearful. His physical exam is unremarkable. He requests police to be called. While calling the police, your charge nurse asks if the Sexual Assault Nurse Examiner (SANE) Hotline should be called? What about the rape crisis advocate?

Discussion

Males can be victims of sexual assault (SA) at any age and these assaults may be perpetrated by other males or females regardless of the victim’s and assailant’s sexual orientation. Though most people are aware of female SA survivors, male victims are often forgotten and neglected due to shame and stigma. It is estimated that one in six boys have been sexually assaulted by their 18^th birthday and one in four men will sustain unwanted sexual events in their lifetime.^1,2 Overall, about five to 10 percent of rape victims are males.^3–5 Male victims may experience SA as part of hazing or initiation rituals, in institutionalized settings, in the military, or while incarcerated. 

There are several differences between male and female victims. However, they each require the same basic health care response: 

1. Safety 
2. Ability to report to law enforcement and to have an appropriate police investigation
3. Access to a rape crisis advocate
4. Access to a medical forensic examination 
5. Access to counseling services
6. Adjudication in court

Male victims are often more reluctant to seek health care and even less likely to seek law enforcement response.^3,5–8 They often are ashamed, embarrassed, and feel they will not be believed or taken seriously. They feel, as a man, they should have been able to prevent or fight off the assault. In addition, some teenagers may think it is a status symbol to have sex with an older woman or man (even if perceived by the victim to be consensual), even if according to state law the act counts as sexual assault.  

There are also several male rape myths that perpetuate the stigma and keep men from seeking treatment.^9–11 First, the reality is that what happened was not controllable or preventable by the victim. And if the perpetrator is male, it does not imply or form the basis for sexual orientation of the victim. Arousal, erection, and ejaculation are not fully controllable and can occur due to stress, anxiety, and penile/anal stimulation. This can cause confusion around consent, enjoyment of the activity, and the victim’s sexual orientation. Table 1 highlights common rape myths.¹¹ Fear of being labeled as homosexual and/or that the rape will make them become homosexual are powerful motivators for males to keep silent and not seek medical, behavioral health, or law enforcement services. Even a feminized name of a rape crisis center may deter male victims from seeking care.  However, the majority of programs do offer very competent, trauma-informed, victim-centered services for males.

FIGURE 1 (click to enlarge): External anal exam using separation technique. Findings include an anal tear (solid arrow) and anal fold redness and some swelling (star).

Studies have shown that females suffer higher rates of penile rape than males, but males show higher rates of digital or object penetration.^4,5,12,13 Thus, anal injury rates are higher in males. Women also sustain higher percentages of bodily injuries.¹³ Also, males tend to have higher rates of multiple assailants, and may have higher rates of rapes involving a weapon.^5,13–15

Emergency Department Care

Emergency departments need to provide male SA victims the same trauma-informed, victim-centered care as female victims.¹⁴ All protocols and procedures should be the same. Rapid triage assessment, including evaluation for potential injuries, should occur. The patient should be placed in a quiet area to await evaluation. All the options should be explained to the patient. The patient should be offered a medical forensic examination by the SANE nurse, accompaniment by the rape crisis advocate, and law enforcement notification. The patient can then accept or decline any or all of the services. Male victims are entitled to the same rights as female victims and exams are to be provided without charge to the patient. These services can be billed to State Crime Victims’ Compensation programs. Patients also have the right to request no law enforcement response and to have anonymous reporting and evidence collection. 

The emergency physician should evaluate the male patient as they would any other female victim. Detailed forensic history should be reserved for the SANE nurse, and the clinician needs to rule out potentially serious injuries and instability. Laboratory and radiographic testing should be performed as indicated. Although rare, some serious injuries seen in male victims include: head injury, fractures, genital injury/mutilation, and anorectal tears and perforation (the patient may present with peritoneal signs).  

Sexually transmitted infection screening and prophylaxis, including HIV, should be provided as per protocol. For those starting HIV post-exposure prophylaxis, medications/prescriptions should be provided and the patient linked to outpatient services. 

The SANE nurse should be consulted for forensic medical examination.¹⁶ The steps and processes are essentially the same for the male patient except for the genital examination. Swabs of the male genitalia should be obtained, paying attention to the penile glans/prepuce, shaft, base, and anterior scrotum. Two moistened swabs are used, but more can be used on each specific outlined area. Male victims may experience anal penetration at a higher rate than female victims, so an anorectal examination should be performed. Swabs should be obtained from the perineum, perianal area, and anal canal.¹⁷ Anoscopy can be performed to look for injuries to more internal structures.¹⁸ Some SANE nurse programs use anoscopy within their scope of practice. Significant anal or rectal trauma may require evaluation by general, trauma, or colorectal surgery. 

Case Resolution

The patient was seen by the emergency physician. No serious injuries were identified during the medical screening examination. Sexually transmitted infection and HIV prophylaxis were initiated. The on-call rape crisis advocate and SANE were called in and law enforcement notified. The SANE nurse collected evidence and turned it over to the police. The SANE nurse found swelling and redness of the anal fold and a small tear. It was determined with the emergency physician that no specific treatment was required and the patient was discharged with all the standard sexual assault referrals. 

Dr. Rozzi is an emergency physician; director of the Forensic Examiner Team at WellSpan York Hospital in York, Pennsylvania; and past-chair of the Forensic Section of ACEP.

Dr. Riviello is chair and professor of emergency medicine at the University of Texas Health Science Center at San Antonio.

References

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