Screening for Sexual Assault

CLINICAL ACTIONS:

ACOG recommends that health care providers screen all women for a history of sexual assault. Screening should take place during routine wellness exams or when presented with symptoms that are suspicious for sexual assault (see ‘Red Flags’ below, in KEY POINTS).  

The National Sexual Violence Resource Center recommends the following to further engage women in a discussion regarding sexual assault  

    • Normalize the subject by including it within the sexual history; ACOG recommends the following introduction  
      • “Because sexual violence is an enormous problem for women in this country and can affect a woman’s health and well-being, I now ask all my patients about exposure to violence and about sexual assault.” 
    • Provide context by connecting the subject to the patient’s health and well-being 
    • Be nonjudgmental 
    • Validate the patient’s responses
  • Ask about sexual experiences that were uncomfortable or unwanted 
      • Have you been touched without your consent? 
      • Have you ever been pressured or forced to have sexual contact? 
    • Do you feel that you have control over your sexual relationships? 

SYNOPSIS:

Key findings of the National Intimate Partner and Sexual Violence Survey reveal that an estimated 1.3 million rape-related physical assaults occur against women annually. Early identification of victims can lead to prevention of long-term and persistent physical and mental health consequences of abuse.  

KEY POINTS:

  • Decide on appropriate interventions depending on each individual situation
  • Pay particular attention to those who report pelvic pain, dysmenorrhea, or sexual dysfunction
  • Red Flags’ for sexual assault include
    • Anxiety
    • Depression
    • Sudden-onset sleep disorders
    • Stress-related complaints
    • Requests for
      • Pregnancy testing
      • Emergency contraception
      • Testing for sexually transmitted diseases
      • Pelvic area trauma
      • Bruising that may be from restraints

Learn More – Primary Sources:

ACOG: Screening Tools – Sexual Assault

ACOG Committee Opinion 777: Sexual Assault

ACOG Committee Opinion 518: Intimate Partner Violence

National Sexual Violence Resource Center

Assessing Patients for Sexual Violence: A guide for health care providers (NSVRC) 

Medical Evaluation of the Rape Victim

CLINICAL ACTIONS:

Sexual assault is unfortunately not an uncommon event, with the National Intimate Partner and Sexual Violence Survey providing a statistic of 1.3 million rape-related physical assaults per year. Some centers have a team trained and available to identify and assist rape victims. However, this is not universal and women’s healthcare providers may be either part of such a team, or may be the initial point of contact and care provider. Important points to consider are as follows:

  • Ask for help if not familiar with performing an examination as proper evidence collection is necessary to prosecute a case
  • Tell a sexual assault victim, if outside the hospital or clinic, to come to a medical facility directly and avoid bathing, cleansing, eating, changing her clothes, urinating, defecation, washing her mouth, cleaning her fingernails, smoking, eating or drinking
  • Obtain history including circumstances of the attack, patient activities after the attack (including bathing, douching), last menstrual period, contraceptive history, previous coitus
  • Physical exam
    • Noting genital and nongenital trauma, foreign material (stains, hair, dirt, etc) colposcopy if available
    • Collect samples of clothing, hair, semen, blood from the patient
    • Collect urine, saliva, buccal mucosa smear, fingernail clipping and scraping, other specimens as indicated
    • Vaginal test for acid phosphatase, saline mount for sperm, trichomonads, bacterial vaginosis, semen analysis for blood group
  • Initial STD exam (CDC)
    • NAATs for C. trachomatis and N. gonorrhoeae at the sites of penetration or attempted penetration
    • NAATs from a urine or vaginal specimen or point-of-care testing (i.e., DNA probes) from a vaginal specimen for T. vaginalis
    • Point-of-care testing and/or wet mount with measurement of vaginal pH and KOH application for the whiff test from vaginal secretions should be done for evidence of BV and candidiasis, especially if vaginal discharge, malodor, or itching is present
      • NAAT also available for BV and candidiasis
    • A serum sample for evaluation of HIV, hepatitis B, and syphilis infections.
  • STD prophylaxis (CDC)
    • Test and provide and empiric antimicrobial treatment for chlamydia, gonorrhea and trichomoniasis

Note: Gonorrhea is now treated with ceftriaxone 500mg IM for individuals weighing <150kg, and 1g for individuals weighing 150kg

  • Hepatitis B
    • Assailant HepB status unknown and survivor is unvaccinated
      • HepB vaccine without HBIG
    • Assailant HepB positive and survivor is unvaccinated
      • HepB vaccine and HBIG
    • Administer
      • At initial exam
      • 1-2 months and 4-6 months after first dose
    • If survivor previously vaccinated but did not receive postvaccination testing
      • single vaccine booster
  • HPV
    • HPV vaccination is recommended for female survivors aged 9–26 years and male survivors aged 9–21 years
    • Administer vaccine to sexual assault survivors at the time of the initial examination with follow-up dose administered at 1–2 months and 6 months after the first dose

HIV Prophylaxis (PEP)

  • Best if started as soon as possible after penetration | Do not give if >72 hours
  • Preferred PEP regimen  (4 weeks)
    • Tenofovir 300 mg PO daily + Emtricitabine 200 mg PO daily plus
    • Raltegravir 400 mg PO twice daily or Dolutegravir 50 mg PO daily
  • CDC guidance (see ‘Learn More – Primary Sources Below) provides further regimen considerations when
    • Source in known to be HIV-infected | Dose adjustments for renal insufficiency | Drug-drug interactions | Recommended alternative regimens
  • Urine for drug screen and pregnancy
    • Offer emergency contraception (see ‘Related ObG Topics’ below)
    • Repeat pregnancy test in 2 weeks

SYNOPSIS:

Nearly 20% of women report having been raped at some time in their lives, according to the CDC 2010 survey. Goals of the rape investigation include: medical assessment and treatment; pregnancy and STD prevention/treatment; collection of forensic data; and psychologic evaluation and support. A form is used to record legal evidence and findings. This may be introduced in court, so should be legible and nontechnical. Some states have programs with designated hospitals, training sites and forensic examiners.

KEY POINTS:

Follow Up

Psychosocial 

  • Psychologic support should be started at presentation; the full effects may not be evident initially
    • Follow-up is important and ideally handled by a specialist trained in rape crisis intervention

STD Follow Up 

  • If initial tests negative and no treatment
    • Repeat STD tests within 1–2 weeks of the assault
  • If treated during the initial visit (regardless of whether testing was performed)
    • Only do post-treatment testing if symptomatic
  • Follow up exam at 1–2 months to look for anogenital warts
  • Syphilis
    • Repeat serologic tests for syphilis if initial test results were negative and infection in the assailant cannot be ruled out
    • Repeat serologic tests for syphilis at 4–6 weeks and 3 months
  • HIV testing
    • Repeat at 6 weeks and at 3 and 6 months using methods to identify acute HIV infection
  • Pregnancy
    • Offer emergency contraception (see ‘Related ObG Topics’ below)
    • Repeat pregnancy test in 2 weeks

Learn More – Primary Sources:

ACOG Committee Opinion 777: Sexual Assault

CDC: National Intimate Partner and Sexual Violence Survey

CDC Violence Prevention: Sexual Violence

CDC: Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV—United States, 2016

CDC: Sexual Assault and Abuse and STDs