1. 8th Edition APGO Objectives for Medical Students Sexual Assault

2. Rationale Rationale: Individuals who are the victims of sexual assault often have significant physical and emotional sequelae.

3. Objective The student will be able to explain medical, forensic, psychological evaluation and treatment, and follow-up of Child sexual assault victim Adult sexual assault victim Acquaintance rape

4. Child Sexual Assault 90% are victimized by parents, family or family friends

5. Child Sexual Assault Medical - forensic Take history without parents present If child displays knowledge of sexual matters, anatomy and physiology, more likely a victim STDs present (note: rare cases nonsexual HPV transmission seen) During examination Avoid sedation Document physical findings Collect appropriate specimens (see Adult Section B below) Adhere to legal “chain of evidence” requirements

6. Child Sexual Assault Treatment - prophylactic antibiotics Amoxicillin 50 mg/kg body weight, PLUS Probenecid 25 mg/kg body weight, OR Spectinomycin 40 mg/kg body weight IM, OR ･ Ceftriaxone 125 mg IM

7. Adult sexual assault victim Immediate emotional care Ensure safety Provide emotional support Be nonjudgmental Be gentle

8. Adult sexual assault victim Encourage victim to describe assault

9. Adult sexual assault victim History General Date and time of assault What acts were committed Age, race, parity Ejaculation? Last menstrual period Bathed since assault

10. Adult sexual assault victim History Sexual Last consensual intercourse Sexual patterns Contraceptive use Alleged assault Penetration Condom use Weapons

11. Adult sexual assault victim Physical General Vital signs Emotional status Body surface - contusions, lacerations, abrasions

12. Adult sexual assault victim Physical General physical exam - skin, mouth, neurologic (trauma), breasts, extremities Genitalia - vulva, vagina Lacerations Abrasions Ecchymoses Hematomas

13. Adult sexual assault victim Forensic collection Describe trauma Take photographs Toxicology screening

14. Adult sexual assault victim Forensic collection Specimen collection Semen Sperm Acid phosphatase Nail clippings Pubic hair combings Blood sample

15. Adult sexual assault victim Forensic collection Culture for gonorrhea, chlamydia Wet prep for motile sperm, trichomonads Collect clothing Offer RPR/VDRL, HIV and Hepatitis B & C testing

16. Adult sexual assault victim Medical treatment All injuries treated appropriately Tetanus toxoid Hepatitis B vaccine (without HBIG) Protects if exposed during assault Two follow-up doses needed

17. Adult sexual assault victim Medical treatment Antibiotic prophylaxis Ceftriaxone 125 mg IM - PLUS Metronidazole 2 gm PO - PLUS Erythromycin 1 gm PO - OR Doxycycline 100 mg PO BID x 7 days

18. Adult sexual assault victim Medical treatment HIV prophylaxis not recommended due to lack of data Pregnancy prevention - emergency contraception offered Psychological management Acute phase adjustment Irritability Tension Anxiety Depression Fatigue Ruminations (persistent)/Flashbacks

19. Adult sexual assault victim Medical treatment Behavioral changes/worsening Alcohol abuse Drug abuse Overeating Post-traumatic stress disorder Extreme fear - counsel or refer for evaluation and management

20. Adult sexual assault victim Follow-up In 2-3 wk. Assess psychologic status Wet prep - R/O, BV, and Trichomoniasis GC, Chlamydia testing Recommend syphilis, HIV serologies in 3-6 mo. Arrange for Hepatitis B vaccine 2nd dose (1-2 mo.) and 3rd dose (4-6 mo.)

21. References Riesenberg D. Treating a societal malignancy-rape. JAMA. 1987;257:726-727. Smith MC. Nonconsensual sex on the college campus: a common occurrence. Clin Pract Sexuality. 1989;4(4):25-28. Stovall TG, Muram D, Wilder M. Sexual abuse and assault: a comprehensive program utilizing a centralized system. Adolesc Pediatr Gynecol. 1988;1:248-251. Adapted from Association of Professors of Gynecology and Obstetrics Medical Student Educational Objectives, 7th edition, copyright 1997

22. Clinical Case Sexual Assault

23. Objectives At the conclusion of this exercise, the student will be able to provide a preliminary assessment and discuss management of patients subjected to sexual assault.

24. Case Presentation A 24-year-old woman was seen in the emergency department at 2:00 am for alleged sexual assault. She reported that she was on a “blind date” and began heavy petting at about midnight. This continued for quite some time, and the “date” would not stop his advances. She stated that she had been held down while her clothes were removed and then was forced to “have sex.” She was very tearful, distraught, agitated and admitted that she had been drinking alcohol.

25. Case Presentation The emergency department staff was very busy with a number of other patients. The gynecologist finally arrived at 4:00 am, although the patient had arrived at 2:00 am. No female assistant or “stand-by” could be found for another hour; so the examination began around 5:30 am.

26. Physical Exam Minor abrasions on the patient’s back and several fresh areas of ecchymoses were noted on her upper arms and breasts. The sexual assault kit materials were used, and specimens were obtained from the vagina, urethra, rectum and oral cavity for analysis and culture. Fingernail clippings, hair brushings and acid phosphatase swabs from the vaginal discharge were obtained. The vaginal discharge was examined and motile sperm were noted on a wet preparation. Laboratory: Cultures, swabs and blood work.

27. Assessment & Plan Assessment Sexual assault Plan Careful history and physical exam Specimen collection/sexual assault kit Take photographs of any injuries Fill out and sign sexual assault chain-of-custody form Notify social services, the assault crisis center and the police Arrange for proper follow-up

28. Discussion Rape has traditionally been defined by law as forcible vaginal penetration without consent. However, this is changing in many states. Many states have redefined rape so that both men and women can be either victim or perpetrator. Some states have degrees of rape, others limit admissibility of a victim’s previous sexual conduct, and others have limited the requirement that the victim’s testimony be corroborated by other evidence. Reforms continue. This case exemplifies “date rape” case in which consent for sexual intercourse cannot be presumed without a clear expression of consent, and because of mere acquiescence to sexual intercourse.

29. Discussion Rape is a crime that is seldom witnessed. Therefore, it is very important that the gathering of corroborating evidence during the medical examination be done in such a way that prosecution can be undertaken. The history and physical examination should be conducted within a standardized legal format. Most hospitals have sexual assault kits for this purpose. The physician should use these instruments precisely and should express no opinions, conclusions or diagnosis in the record. The record should describe the physician’s findings and examination methods in detail.

30. Discussion Informed consent should be obtained before the examination that will allow photographs and passage of information to authorities, as well as a routine examination. There may be reporting requirements in the jurisdiction of your practice, especially if the patient is a minor. The examination should involve general inspection for signs of trauma, evaluation of external genitalia and a vaginal speculum examination. Certain features are critical. Any external lesions should be photographed. The external genitalia should be carefully inspected. Sexual dysfunction is common among rapists, and failure to ejaculate or erectile failure may make internal vaginal fluid specimens unhelpful. In such instances, signs of soft tissue trauma to the genitalia may be the only corroborating evidence. Likewise, acid phosphatase assays from vaginal secretions may be very helpful when the rapist has had a vasectomy and the semen contains no sperm. Fifty percent of tests run 12 hours after intercourse show acid phosphatase concentrations in the normal range, making the timing of the examination important, as well. Blood serotyping and genetic screenings are becoming important aspects of sexual assault evaluations.

31. Discussion All specimens should be collected in the presence of a witness and taken directly to the pathologist. Anyone participating in this system of collection and transport must sign a chain-of- custody statement to avoid mistakes or exchanges of specimens. Any break in the chain of custody makes it impossible to prosecute a case.

32. Discussion It is important for physicians to be ready to testify in court if prosecution is attempted. Hearsay rules may prevent evidence alone from the examination to be admitted, although this is less common when evidence is properly labeled. This can be the first contact with the legal system for the obstetrician- gynecologist. In this setting, the physician serves as a patient advocate and an expert witness within the system, making it an ideal introduction to law. Over time, proper legal management of a sexual assault evaluation may be as therapeutic as appropriate medical management, which could include long-term psychotherapy.

33. Teaching Points 1. In sexual assault cases, the physician has two clear duties: 1) medical treatment of the patient; and 2) collection and preservation of evidence. 2. The evidence must be collected with care and completeness, and chain-of-custody requirements must be maintained or such evidence may be inadmissible in court. 3. Having available persons from social services who can provide immediate counseling and emotional support in an emergency department setting is often helpful.