1. Panelists:William Alt, BSN RN Jessica Keith, PhD Lisa Nocera, MD Moderator:Aimee Sanders, MD MPH Acute Sexual Assault

2. Statistics

3. Myths about Sexual Assault Sexual assault is primarily a sexual crime. Sexual assault happens only to young women. Sexual assault is not possible within marriage. Women can incite men to rape. There is a “right way” to respond in a rape situation. False reporting of sexual assault is common.

4. Nina’s Arrival

5. Sunday, 4:00 am 32yo female Veteran with a friend close by Avoiding eye contact “I’m not feeling well. I think I have a bladder infection.” Tearfully, she discloses she was raped hours earlier

6. The Silent Violent Epidemic

7. Subtle Presentations of Acute Sexual Assault

9. Nina’s Triage Positive exchange from the beginning and from all involved Hemodynamically stable ESI = 2 Immediately place in private, gender-specific treatment room Allow support person, if desired Notify Charge Nurse and ED provider

10. Compassionate Care

11. Immediate Responsibilities

12. Top Priority Address life-threats and serious injuries -Forensic evidence collection is secondary Remain mindful of any potential evidence while providing care

13. Documented informed consent for: –Reporting to law enforcement –Physical examination –Medical treatment –Forensic examination* *signature consent Immediate Responsibilities

14. Reporting Requirements

15. Restore sense of control and safety Counsel on risks and benefits of proposed care Emphasize right to care even if chooses not to report Right to refuse any aspect of care and still receive desired treatment Immediate Responsibilities

16. Know appropriate MH provider in advance Engage emergently if suicidal ideation or self-harm Acknowledge survivors have right to decline MH services Provide VA, private, and public resources

17. Nina’s Dilemma No physical injuries Non-mandatory reporting state Declines police involvement Ambivalent about evidence collection Friend is present Interested in MH Concerns: STI and preventing pregnancy

18. Counseling on Reporting and Evidence Collection

19. Survivor Decision-Making

20. Documentation Use factual, clinical, non-judgmental language for descriptions Medically relevant information as reported –Time and setting of the sexual assault –Nature of assault (oral, vaginal, rectal penetration) –Number of assailants –Injuries, exposure to bodily fluids –Threats, weapons and/or restraints used –Post-assault activities (urinating, eating, bathing, etc.)

21. Drug-Facilitated Sexual Assault Common drugs currently used –Alcohol Most common –Benzodiazepines (flunitrazepam) –Ketamine –Gamma hydroxybutyrate (GHB)

22. Survivors of drug-facilitated sexual assault may present with…

24. Medical Exam and Clearance

25. Precautions to preserve evidence –Minimal handling of clothing –Gloves (change when cross-contamination could occur) –If clothing removed, undress over 2 sheets, place clothing/top sheet in paper bag –Patient identification on all evidence collected –Minimize transfers of evidence –Counsel against activities that destroy evidence Use clinical judgment & common sense

26. Transfer Process

27. Facilitating Transfer

28. Forensic Sexual Assault Exam All EDs & UCCs must have an exam kit in the event survivor is too unstable for transfer Head-to-toe exam with pelvic exam to document injuries and collect evidence Chain of custody for evidence collected Right to decline any portion and still have desired portions performed

29. Transition and loss of therapeutic relationships can be stressful

30. Nina’s Decisions Declines transfer Declines forensic exam Requests medical treatment Nina’s Decisions

31. If the survivor declines transfer, providers should offer…

32. Nina’s Care & Treatments Pregnancy prophylaxis Empiric STI treatment HIV testing Antiretroviral prophylaxis initiated Immunity to hepatitis B documented Psychiatrist and ED SW closely involved

33. Follow-Up Recommendations Medical follow-up at 2, 6, 12 & 24 weeks - Injuries - STI - HIV - Pregnancy testing - Hepatitis B vaccine (at 1 month) Return if any concerning signs/symptoms

34. Aftercare Instructions Arrange support presence Educate on common psychological responses –PTSD-like symptoms –Denial or repressive responses Normalize these responses Reassure responses will slowly diminish over time –If they don’t, VA services are available

35. Safety Consider alternative arrangement if assailant is known to survivor Develop safety plan Make aware can return to ED/UCC Inquire if children in the home Follow state reporting laws

36. Nina’s Conclusion

37. Key Points Non-Judgmental Approach Compassionate Care Informed Consent Survivor’s Rights Psychosocial Support

39. Resources American College of Emergency Physicians. Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient, 2 nd ed. Dallas, TX: ACEP, 2013. www.acep.org/content.aspx?id=93246 www.acep.org/content.aspx?id=93246 Ball & Shearer. Current guidelines on HIV postexposure prophylaxis for nonoccupational exposures, including sexual assault. EM Practice Guidelines Update 2013;5(10):1-15. Centers for Disease Control. Sexual violence: Facts at a glance, 2012. http://www.cdc.gov/ViolencePrevention/pdf/sv- datasheet-a.pdfhttp://www.cdc.gov/ViolencePrevention/pdf/sv- datasheet-a.pdf 39

40. Centers for Disease Control. Sexually transmitted disease treatment guidelines, 2010: Sexual assault and STDs, adults and adolescents. Atlanta, GA: CDC, 2011. http://www.cdc.gov/std/treatment/2010/sexual-assault.htm http://www.cdc.gov/std/treatment/2010/sexual-assault.htm Galjour JL. Current guidelines for management of sexually transmitted diseases, emergency contraception, and sexual assault in the emergency department. EM Practice Guidelines Update 2011;3(8):1-12. Hogan &Uyenishi. Sexual assault: Medical and legal implications of the emergency care of adult victims. Emerg Med Pract 2003; 5(3):1-20. Ledray, LE. Sexual Assault Nurse Examiner (SANE) Development & Operation Guide. Washington, DC: US Department of Justice, Office of Justice Programs, Office for Victims of Crime, 1999. https://www.ncjrs.gov/ovc_archives/reports/saneguide.pdf https://www.ncjrs.gov/ovc_archives/reports/saneguide.pdf 40

41. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. CDC fact sheet: Gonorrhea treatment guidelines: Revised guidelines to preserve last effective treatment option. Washington, DC: Centers for Disease Control, 2013. http://www.cdc.gov/nchhstp/newsroom/docs/Gonorrhea- Treatment-Guidelines-FactSheet.pdf http://www.cdc.gov/nchhstp/newsroom/docs/Gonorrhea- Treatment-Guidelines-FactSheet.pdf Schafran, LH. Barriers to credibility: Understanding and countering rape myths. National Judicial Education Program, 2014. http://www.nationalguard.mil/Portals/31/Documents/J1/SAPR/S ARCVATraining/Barriers_to_Credibility.pdf http://www.nationalguard.mil/Portals/31/Documents/J1/SAPR/S ARCVATraining/Barriers_to_Credibility.pdf Sharkansky, E. Sexual trauma: Information for women’s medical providers. Washington, DC: US Department of Veterans Affairs, National Center for PTSD, 2014. http://www.ptsd.va.gov/professional/treatment/women/ptsd- womens-providers.as http://www.ptsd.va.gov/professional/treatment/women/ptsd- womens-providers.as 41

42. Veterans Health Administration. Assessment and management of Veterans who have been victims of alleged acute sexual assault. VHA Directive 2010-014. Washington, DC: US Department of Veterans Affairs, VHA, 2010. http://www1.va.gov/vhapublications/ViewPublication.asp?pub_I D=2177 http://www1.va.gov/vhapublications/ViewPublication.asp?pub_I D=2177 Veterans Health Administration. Emergency Medicine Handbook. VHA Handbook 1101.05. Washington, DC: US Department of Veterans Affairs, VHA, 2010. http://www1.va.gov/vhapublications/ViewPublication.asp?pub_I D=2231 http://www1.va.gov/vhapublications/ViewPublication.asp?pub_I D=2231 Veterans Health Administration. Health Care Services for Women Veterans. VHA Handbook 1330.01. Washington, DC: US Department of Veterans Affairs, VHA, 2010. http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID =2246 http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID =2246 42