Obstetrics & Gynecology>>>>>Sexual Abuse and Intimate Partner Violence
Question 5#

You are evaluating a 19-year-old victim of sexual assault in the emergency department. As a physician, your legal requirement includes which of the following?

a. Identification of the attacker
b. Detailed notation of injuries
c. Delivery of evidence to a law enforcement facility
d. Treating patient even if she refuses
e. Writing the diagnosis of rape in the patient’s chart

Correct Answer is B

Comment:

When possible, the acute evaluation of sexual assault victims should be undertaken by someone with specific training to care for victims of sexual assault. Complete evaluations are time intensive and require several hours. Your legal requirement as a physician evaluating a sexual assault victim includes documentation of history, examination and notation of injuries, and collection of clothing and vaginal, rectal, oropharynx, pubic hair samples, and fingernail scrapings, as appropriate, for testing. The history should focus on precise details of the sexual assault, and should be obtained in a sensitive and supportive environment. The examination should describe emotional state, and should document any evidence of trauma. The forensic evaluation requires informed consent. Forensic specimens must be submitted to the proper authorities in a timely manner. You must submit any specimens to forensic authorities and receive a receipt for the patient’s chart. Since rape and assault are legally defined terms, they should not be stated as a diagnosis. The CDC recommends that the following laboratory tests be considered to evaluation for sexually transmitted infections in victims of sexual assault. These are as follows: gonorrhea and chlamydia nucleic acid amplification tests from the vagina, anus, and throat; DNA probe for trichomonas vaginalis; and serum testing for hepatitis B, syphilis, and HIV. Whether or not to test for these infections should be individualized. The CDC also recommends antibiotic prophylaxis, since many assault victims will not return for follow up. Prophylaxis should be directed at treating the most common infections, including gonorrhea, chlamydia, and trichomonas. The recommended treatment is ceftriaxone 250 mg intramuscularly in a single dose plus azithromycin 1 g orally in a single dose, plus metronidazole 2 g orally in a single dose. Post-exposure hepatitis B vaccination and HIV prophylaxis are also recommended. “Emergency contraception” (medication prophylaxis) to prevent pregnancy should be offered to women following sexual assault. A pregnancy test should be performed to exclude pregnancy. 

Nausea is a very common side effect with combination estrogen/progestin pills used for emergency contraception. Plan B, a progestin-only form of emergency contraception, has a much lower rate of nausea and is better tolerated, making it the preferred choice. Prophylaxis can be given up to 72 hours after the assault, but has been shown to be effective up to 5 days after the rape. Emergency contraception has efficacy rates of 74% to 89%. Patients should be informed that their next menses may be delayed and counseled to get a pregnancy test if it is delayed more than 2 weeks. A copper IUD can be inserted for emergency contraception but should be avoided until active infection can be ruled out. Following the assault, the patient should receive follow-up counseling within 24 to 48 hours, and subsequent follow-up appointments can be arranged at 1 and 4 weeks. The patient should not leave without plans for follow-up. Psychosocial support is an important part of recovery for assault survivors. The reorganization phase of the rape trauma syndrome involves long-term adjustments and may last for months to years. Flashbacks and nightmares may continue and phobias may develop. Victims may also make many new lifestyle changes (eg, moving, making new friends, getting a new job). This is an attempt by victims to regain control over their lives. Medical and counseling care should remain nonjudgmental, sensitive, and attuned to the patient’s overall well-being. It is important for the patient to continue counseling during this time for full recovery to be achieved.