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
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?
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.
Decide on appropriate interventions depending on each individual situation
Pay particular attention to those who report pelvic pain, dysmenorrhea, or sexual dysfunction
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
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
Assailant HepB status unknown and survivor is unvaccinated
HepB vaccine without HBIG
Assailant HepB positive and survivor is unvaccinated
HepB vaccine and HBIG
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 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
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.
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
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
Repeat at 6 weeks and at 3 and 6 months using methods to identify acute HIV infection
Offer emergency contraception (see ‘Related ObG Topics’ below)
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This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
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presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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