Management of Rape Victims Martin Donohoe This presentation was last updated in the early 2000s – I recommend consulting more 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 annual incidence  80/100,000 women annual incidence  80/100,000 women 7% of all violent crimes 7% of all violent crimes lifetime prevalence 10% - 25% lifetime prevalence 10% - 25%

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 Homeless and runaways Homeless and runaways

“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 = % 1 -2/1,000 odds of acquiring HIV 1 -2/1,000 odds of acquiring HIV varies varies

Rape Underreported Underreported Less than 1% of rapists convicted Less than 1% of rapists convicted 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

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

Physical Examination of Sexual Assault Victims Collection of clothing Collection of clothing External evaluation External evaluation abrasions, lacerations, ecchymoses, bite marks abrasions, lacerations, ecchymoses, bite marks Oral cavity Oral cavity secretions, injuries, cultures secretions, injuries, cultures NEJM 1995; 332:234-7

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

Prophylaxis for Adult Victims of Sexual Assault Antibiotic Prophylaxis Ceftriaxone (250 mg IM) or Spectinomycin (2 g IM) Ceftriaxone (250 mg IM) or Spectinomycin (2 g IM)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 2 OCP tablets (each with 50 mcg ethinyl estradiol) po q12  x 2 2 OCP tablets (each with 50 mcg ethinyl estradiol) po q12  x 2OR 3 OCP tablets (each with 35 mcg ethinyl estradiol) po q12  x 2 3 OCP tablets (each with 35 mcg ethinyl estradiol) po q12  x 2PLUS Antiemetic Antiemetic

HIV Post-Exposure Prophylaxis for Adult Victims of Sexual Assault HIV Prophylaxis (studies ongoing) HIV Prophylaxis (studies ongoing) 2 nucleoside analogues (zidovudine 300 mg po bid and lamivudine 150 mg po bid or Combivir 1 po bid)+ 1 protease inhibitor (tenofovir 300 mg po qd) 2 nucleoside analogues (zidovudine 300 mg po bid and lamivudine 150 mg po bid or Combivir 1 po bid)+ 1 protease inhibitor (tenofovir 300 mg po qd) start up to 72  after rape start up to 72  after rape

HIV Post-Rape Prophylaxis 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 Treat for 4 weeks if perpetrator HIV+ or if perpetrator’s status unknown Treat for 4 weeks if perpetrator HIV+ or if perpetrator’s status unknown D/C treatment if perpetrator’s serologic HIV test confirmed negative and no acute retroviral syndrome in exposed patient D/C treatment if perpetrator’s serologic HIV test confirmed negative and no acute retroviral syndrome in exposed patient

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 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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