Management of Rape Victims Martin Donohoe Information within does not constitute clinical advice regarding treatment – I recommend consulting contemporary medical references

Rape Unwanted, forced penetration (oral/vaginal/anal) Unwanted, forced penetration (oral/vaginal/anal) Reported by % of women who are physically abused Reported by % of women who are physically abused

Rape Annual incidence  80/100,000 women Annual incidence  80/100,000 women 7% of all violent crimes 7% of all violent crimes Lifetime prevalence up to 25% Lifetime prevalence up to 25% 1/3 Native Americans/Alaskan Natives victims of attempted rape or rape 1/3 Native Americans/Alaskan Natives victims of attempted rape or rape Migrants, those in war zones and refugee camps at high risk Migrants, those in war zones and refugee camps at high risk

Rape Annual incidence of at least 300,000  women in US Annual incidence of at least 300,000  women in US Forcible rape every 6.2 seconds (FBI) Forcible rape every 6.2 seconds (FBI) 7% of all violent crimes 7% of all violent crimes Additional 3.7 million confronted with unwanted sexual activity Additional 3.7 million confronted with unwanted sexual activity Lifetime prevalence 13-39% in women; 3% in men Lifetime prevalence 13-39% in women; 3% in men

Epidemiology of VAW 2011 CDC study 2011 CDC study 18% of women have been raped; 1.4% of men 18% of women have been raped; 1.4% of men Women: 52% by partner; 41% by acquaintance Women: 52% by partner; 41% by acquaintance Men: 52% by acquaintance; 15% by stranger Men: 52% by acquaintance; 15% by stranger

Date Rape 40% of college women report forced sexual contact, attempted rape, or completed rape 40% of college women report forced sexual contact, attempted rape, or completed rape independent of school demographics independent of school demographics

Date Rape  25% of college males admit to using sexually coercive behaviors  25% of college males admit to using sexually coercive behaviors 2/3 of college males report engaging in unwanted sexual intercourse 2/3 of college males report engaging in unwanted sexual intercourse reasons: peer pressure, desire to be liked reasons: peer pressure, desire to be liked

Spousal Rape % of all marriages % of all marriages more violent, less frequently reported then non-spousal rape more violent, less frequently reported then non-spousal rape not illegal in many U.S. states/other countries not illegal in many U.S. states/other countries

High Risk Groups Prostitutes Prostitutes Military Military See the “Women’s Health” and “War and Peace” pages of the Public Health and Social Justice website for other slide shows and articles covering: See the “Women’s Health” and “War and Peace” pages of the Public Health and Social Justice website for other slide shows and articles covering: Violence against women in the military Violence against women in the military War, rape and genocide War, rape and genocide Homeless and runaways Homeless and runaways

High Risk Groups Gays, lesbians, bisexuals, transgendered Gays, lesbians, bisexuals, transgendered Alcohol and drug users Alcohol and drug users College students College students Persons under age 24 Persons under age 24

“High Risk” Perpetrators Male college athletes Male college athletes Fraternity members Fraternity members Men with restraining orders Men with restraining orders

Rape 5% chance of pregnancy 5% chance of pregnancy 25% chance of acquiring STD 25% chance of acquiring STD GC = % GC = % Chlamydia = % Chlamydia = % Syphilis = % Syphilis = %

Rape 5% chance of pregnancy 5% chance of pregnancy 25% chance of acquiring STD 25% chance of acquiring STD GC = % GC = % Chlamydia = % Chlamydia = % Syphilis = % Syphilis = %

Rape and HIV 1 -2/1,000 odds of acquiring HIV from HIV+ rapist 1 -2/1,000 odds of acquiring HIV from HIV+ rapist 1-2/100,000 overall risk of HIV from vaginal penetration 1-2/100,000 overall risk of HIV from vaginal penetration 2-3/10,000 from anal penetration 2-3/10,000 from anal penetration

Rape and Pregnancy Noninvasive prenatal genetic testing through amplification of fetal alleles from maternal blood very accurate for identifying father Noninvasive prenatal genetic testing through amplification of fetal alleles from maternal blood very accurate for identifying father Can be performed at 8-14 weeks gestation Can be performed at 8-14 weeks gestation vs. amniocentesis and chorionic villus sampling (10-15 weeks, risks to mother and fetus) vs. amniocentesis and chorionic villus sampling (10-15 weeks, risks to mother and fetus) May assist mother’s decision to carry vs. terminate pregnancy May assist mother’s decision to carry vs. terminate pregnancy

Rape Underreported (16-38% notify law enforcement; 17-43% present for medical evaluation) Underreported (16-38% notify law enforcement; 17-43% present for medical evaluation) Fewer than ½ of rape cases successfully prosecuted; as few as 1% of rapists convicted Fewer than ½ of rape cases successfully prosecuted; as few as 1% of rapists convicted

Rape Large backlog of untested rape kits (over 180,000) Large backlog of untested rape kits (over 180,000) H.R and S.B 2736 (Justice for Survivors of Sexual Assault) bills pending in Congress H.R and S.B 2736 (Justice for Survivors of Sexual Assault) bills pending in Congress

Rape Average prison time for those convicted: Average prison time for those convicted: rape = 1 year rape = 1 year armed robbery = years armed robbery = years murder = 8 years murder = 8 years Chemical Castration Laws Chemical Castration Laws

The Physician’s Duties in Caring for Victims of Sexual Assaults Medical Medical medical history medical history evaluate and treat physical injuries evaluate and treat physical injuries cultures cultures treat pre-existing infections treat pre-existing infections NEJM 1995; 332:234-7 and NEJM 2011;365: NEJM 1995; 332:234-7 and NEJM 2011;365:834-41

The Physician’s Duties in Caring for Victims of Sexual Assaults Medical Medical offer post-exposure HIV prophylaxis offer post-exposure HIV prophylaxis offer post-coital contraception (vs. in utero paternity testing f/b selective abortion) offer post-coital contraception (vs. in utero paternity testing f/b selective abortion) arrange medical followup arrange medical followup provide counseling provide counseling NEJM 1995; 332:234-7 and NEJM 2011;365: NEJM 1995; 332:234-7 and NEJM 2011;365:834-41

Physical Examination of Sexual Assault Victims Collection of clothing Collection of clothing External/internal evaluation External/internal evaluation abrasions, lacerations, ecchymoses, bite marks; colposcopy, toluidine blue staining abrasions, lacerations, ecchymoses, bite marks; colposcopy, toluidine blue staining Oral cavity Oral cavity secretions, injuries, cultures secretions, injuries, cultures Note: time limits for evidence collection vary by state ( hrs) Note: time limits for evidence collection vary by state ( hrs) NEJM 1995; 332:234-7 and NEJM 2011;365: NEJM 1995; 332:234-7 and NEJM 2011;365:834-41

Physical Examination of Sexual Assault Victims Genitalia Genitalia hair combing, hair sampling, vaginal secretions, injuries, cultures hair combing, hair sampling, vaginal secretions, injuries, cultures Rectum Rectum injuries, cultures injuries, cultures NEJM 1995; 332:234-7 and NEJM 2011;365: NEJM 1995; 332:234-7 and NEJM 2011;365:834-41

Prophylaxis for Adult Victims of Sexual Assault Antibiotic Prophylaxis Ceftriaxone (250 mg IM) or cefixime (2 g po) Ceftriaxone (250 mg IM) or cefixime (2 g po)PLUS Doxycycline (100 mg po bid x 7d) or Azithromycin (1 g po x 1) Doxycycline (100 mg po bid x 7d) or Azithromycin (1 g po x 1)PLUS Metronidazole ( 2 g po x 1) Metronidazole ( 2 g po x 1)

Prophylaxis for Adult Victims of Sexual Assault Prevention of Pregnancy Most effective oral regimen: 1 dose of 30 mg ulipristal or 1.5 mg levonorgestrel within 120 hours of unprotected intercourse (ulipristal twice as effective; 0.9% pregnancy rate vs 1.7%) Most effective oral regimen: 1 dose of 30 mg ulipristal or 1.5 mg levonorgestrel within 120 hours of unprotected intercourse (ulipristal twice as effective; 0.9% pregnancy rate vs 1.7%)

Prophylaxis for Adult Victims of Sexual Assault Prevention of Pregnancy Alternate regimen: 2 doses of 100 mcg ethinyl estradiol plus 0.5 mg levonorgestrel taken 12 hours apart (plus prn antiemetic) Alternate regimen: 2 doses of 100 mcg ethinyl estradiol plus 0.5 mg levonorgestrel taken 12 hours apart (plus prn antiemetic) Most effective: IUD implanted within 5 days Most effective: IUD implanted within 5 days Nearly 100% effective Nearly 100% effective

HIV Post-Exposure Prophylaxis for Adult Victims of Sexual Assault HIV Prophylaxis HIV Prophylaxis Consult ID Consult ID start up to 72  after rape start up to 72  after rape Baseline HIV test and referral to experienced clinician within 72 hours of starting PEP Baseline HIV test and referral to experienced clinician within 72 hours of starting PEP

Hepatitis B Post-Exposure Prophylaxis for Adult Victims of Sexual Assault Offender HBsAg-positive: administer Hep B vaccine and HBIG Offender HBsAg-positive: administer Hep B vaccine and HBIG Offender’s HBsAg status unknown: administer Hep B vaccine Offender’s HBsAg status unknown: administer Hep B vaccine Rx ideally within 24 hrs, but may be effective up to 14 days Rx ideally within 24 hrs, but may be effective up to 14 days Complete Hep B vaccine series Complete Hep B vaccine series Tetanus booster if indicated Tetanus booster if indicated

Ensure Victim’s Safety Social worker involvement Social worker involvement Restraining order Restraining order Phone numbers of shelters, hotlines Phone numbers of shelters, hotlines Safe place to go Safe place to go

Domestic Violence Shelters Availability poor Availability poor up to % of women and 80% of children turned away on any given night up to % of women and 80% of children turned away on any given night 4 times as many animal shelters as domestic violence shelters in U.S. 4 times as many animal shelters as domestic violence shelters in U.S.

Domestic Violence Shelters Woefully underfunded Woefully underfunded Average length of stay = 14 days; most allow 30 day max stay Average length of stay = 14 days; most allow 30 day max stay Over 50% of all homeless women and children are fleeing domestic violence Over 50% of all homeless women and children are fleeing domestic violence

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