Sexual Assault Case File

Sexual Assault Case File

Eugene C. Toy, MD, Patti Jayne Ross, MD, Benton Baker III, MD, John C. Jennings, MD

CASE 31

A 24-year-old G0P0 woman is brought into the emergency center by police due to a sexual assault. The preliminary information is that the woman was attacked by an unknown male assailant while she was jogging in a nearby park. She reported that she is not sexually active and uses no form of contraception. She experienced vaginal penetrated penile intercourse while being threatened with a knife. On examination, the patient appears anxious and tearful. Her blood pressure (BP) is 130/70 mmHg, heart rate (HR) is 90 beats per minute (bpm), and she is afebrile.

» What are the priorities in the management of this patient?

» What special approach must be undertaken in the examination?

» What infections are most likely to be acquired?

» What medications (if any) should be offered?

ANSWER TO CASE 31:

Sexual Assault                                           

Summary: A 24-year-old nulliparous woman is brought into the emergency center by police due to a sexual assault. She is not currently sexually active and does not use contraception. She experienced vaginal penetrated penile intercourse by an unknown male assailant, and was threatened with a knife. On examination, the patient appears anxious and tearful. Her vital signs are normal.

• Priorities in management: Treat acute and/or life-threatening medical issues, perform a careful history and physical examination, order appropriate lab and sexually transmitted infection (STI) testing, arrange for emergency contraception and STI prophylaxis, and provide psychosocial support and counseling.
• Special approach in the examination: Exercise patience and gentleness, gain informed consent, approach the exam with sensitivity, and collect samples appropriate for local regulation and ensuring the chain of custody for legal reasons.
• Most common infections: Trichomonas, Chlamydia, gonorrhea, and hepatitis B.
• Medications offered: Ceftriaxone intramuscular (IM), oral metronidazole, and oral azithromycin, and if not previously vaccinated, hepatitis B immune globulin (HBIG) and hepatitis B vaccine, as well as emergency contraception.

ANALYSIS

Objectives

1. Define sexual assault and the incidence and prevalence.
2. Describe the legal, emotional, social, and medical approach to the sexual assault victim.
3. Describe postexposure prophylaxis for the sexual assault victim.
4. Be aware of elder abuse and describe physical exam findings.
5. Be aware of domestic abuse, recognize the signs, and the interventions.

Considerations

This is a case of a 24-year-old nulliparous woman brought into the emergency center by police due to a sexual assault. She reports to have been raped at knifepoint by an unknown male assailant at a nearby park. The patient appears anxious and tearful. Sexual assault is a crime of violence, and can result in significant physical and emotional trauma and injury. A coordinated and multidisciplinary approach is optimal to minimize trauma and connect the patient to community resources. The exam should be victim-centered, meaning that the order of the exam may need to be modified depending on the patient’s cultural or emotional needs. Informed consent is crucial, and should be gained through the process including medical care, pregnancy testing, testing and prophylaxis for STI, human immunodeficiency virus (HIV) prophylaxis, photographs, and permission to contact the patient for follow-up on test results. The first priority is to identify and treat any life threatening injury. As much as possible, the examination should be coordinated with evidence collection to minimize discomfort to the patient. Many emergency centers have Sexual Assault Forensic Examiners, who have special training, expertise, and knowledge of how to collect evidence to meet legal requirements. The patient should be counseled in a language that is most comfortable. Confidentiality is complex in these settings, and should be carefully discussed with the patient, so that the patient may be aware of what information may be part of the criminal justice record (information shared with law enforcement, justice system advocates, etc), and what evidence and lab results may become legal evidence and not privileged. Testing for sexually transmitted infections should be individualized. A pregnancy test should be performed. The most common infections identified after a sexual assault are trichomonas, gonorrhea, chlamydia and hepatitis B. Thus, the patient should be encouraged to accept STI prophylaxis. A common regimen is ceftriaxone 250 mg IM, metronidazole 2 g orally, and azithromycin 1 g orally. If the patient has not been vaccinated for hepatitis B, then HBIG as well as the full hepatitis B vaccine is recommended. HIV postexposure prophylaxis should be discussed with the patient, taking into account the risk factors for exposure. Pregnancy prevention should be discussed and emergency contraception should be offered. Finally, support to community resources, arrangements for follow-up, and referral for reporting to the legal authorities should be undertaken if not already done.

APPROACH TO:

Sexual Assault and Domestic Violence                                              

DEFINITIONS

SEXUAL ASSAULT: Any sexual act, ranging from sexual coercion to contact abuse to rape including genital, oral, or anal penetration, performed by one person on another without consent.

ACQUAINTANCE RAPE: Sexual assault committed by someone known to the victim.

DATE RAPE: When the sexual assault occurs in the context of a dating relationship.

STATUTORY RAPE: Sexual intercourse with a person under an age specified by state law, in many states it is 16 to 18 years old.

CHILD SEXUAL ABUSE: Refers to an interaction between a child and an adult, when the child is being used for sexual stimulation of the adult.

INTIMATE PARTNER VIOLENCE: Control by one partner over another in a dating, marital, or live-in relationship. The control can include physical, sexual, emotional or economic abuse and/ or threats, and isolation.

INCEST: A form of acquaintance rape, in which the assailant is a family member; includes parental figures who live in the home.

ELDERLY ABUSE: A single or repeated act, or lack of appropriate actions, which causes injury or distress to an individual 60 years older and occurs within a relationship where there is an assumption of trust, or when the act is directed toward an elder person due to their age or impairments. It can be physical, psychological, emotional, or sexual abuse, neglect, abandonment, or financial exploitation.

MARITAL RAPE: Forced coitus or related sexual acts within a marital relationship without consent of the partner.

SEXUAL COERCION: The use of nonphysical tactics to gain sexual contact with a nonconsenting partner, may include intentional use of drugs or alcohol to lower inhibitions.

POSTTRAUMATIC STRESS DISORDER: A disorder developing after a traumatic event that involves re-experiencing the trauma, avoidance of activities that may be associated with the trauma, and a state of hyperarousal.

CLINICAL APPROACH

Sexual assault is a term that encompasses rape, unwanted genital touching, and sexual coercion. It is a complex problem with many medical, psychological, and legal aspects. The lifetime prevalence of sexual assault is reported as approximately 20% but this is likely an underestimation due to reporting bias. The majority of reported assailants are known to the victim—either a current or former intimate partner, acquaintance, or family member. Fourteen percent of reported assailants are strangers. Those at increased risk for sexual assault include the physically or mentally disabled, homeless, and persons who are gay, lesbian, bisexual, or transgendered. Other populations at risk are college students, alcohol and drug users, and persons under age 25 years.

Sexual assault can lead to physical injury in approximately half of cases, and emotional trauma, fear, and embarrassment in the majority of cases. Many victims fear that they will not be heard or believed, or that details about their assault will be released to the public. They may also fear for their safety, or fear that their case will not be successfully prosecuted. Sexual assault victims may be hesitant to seek medical attention after the inciting event so it is important for healthcare providers to understand that the patient may be guarded in her verbal and nonverbal responses. Prior to examination, the patient must be instructed not to bathe, eat, drink, clean fingernails, smoke, urinate nor defecate. All of these actions may alter important legal data collection.

The initial role of the healthcare provider is to rule out any life-threatening injuries as with any patient triaged through a medical facility. Although most physical injuries are reported as minor, about 1% report major injuries needing hospitalization or operative repair, and 0.1% suffer fatality. After life-threatening injuries have been ruled out, the patient must be moved to a quiet, private room for the remainder of the exam and informed consent must be obtained (Figure 31– 1). A thorough history and physical examination must be taken that includes: details of the event with a description of her attacker, last menstrual period, and contraceptive use. Next, patient should be instructed to undress on a white sheet and the clothes collected for legal purposes. A head to toe examination needs to be performed, searching for bruises, lacerations, and bite marks, including a thorough documentation of the pelvic examination. Photographs may be placed in the medical record to aid in the documentation.

Figure 31–1. Examination of a sexual assault victim.

Vaginal swabs should be taken on speculum exam, which can be used to perform deoxyribonucleic acid (DNA) evaluation, noting the presence of motile sperm on microscopy, as well as cultures for Neisseria gonorrhea, Chlamydia trachomatis, and Trichomonas vaginalis. Pubic hair combings, fingernail scrapings, and skin washings need to be collected as well. A Wood’s lamp can be used to assess clothing for semen. Colposcopic evaluation with toluidine blue can assess microscopic abrasions that may be missed on gross examination. Serologic tests for hepatitis B virus, HIV, and Syphilis should also be performed. Collection of these samples and thorough documentation play a pivotal role from a legal and medical perspective, and any healthcare provider that does not feel comfortable proceeding with the necessary steps, must seek assistance from experienced personnel (see Figure 31– 1 for algorithm of the examination of a sexual assault victim).

The risk of pregnancy after sexual assault is estimated to be between 2% and 4%. Emergency contraceptives should be given within 72 hours of the assault, but may be effective if given within 120 hours. A serum pregnancy test must be documented in the chart prior to administering any method of contraception to rule out a preexisting pregnancy. The most effective form of emergency contraception is the copper intrauterine device if inserted within 120 hours postcoital and patients may benefit from the long-term retention.

There are three main regimens for oral emergency contraception: progestinonly pills, combined oral contraceptives, and antiprogesterone pills (Table 31– 1). See also case 44 (contraception) for more details.

Prophylactic antibiotics for sexually transmitted infections are indicated for chlamydial, gonococcal, and trichomonal infections. Administering ceftriaxone 250mg intramuscularly in a single dose, metronidazole 2g orally in a single dose, as well as azithromycin 1g orally in a single dose or doxycycline 100mg twice daily orally for 7 days are the recommended treatment for these infections (see Table 31–2).

Post exposure prophylaxis (PEP) is also recommended for hepatitis B virus and risk individualization for HIV. The regimen according to the 2015 CDC guidelines include receiving both hepatitis B immunoglobulin in addition to hepatitis B vaccine if the assailant is hepatitis B positive and the victim unvaccinated. HIV PEP is risk dependent; however, the CDC recommends administering 28 days of zidovudine within 72 hours of assault, to higher risk patients outlined in the algorithm (Figure 31– 2). Additionally, Human Papilloma Virus vaccine is recommended for female victims aged 9 to 26 years, and may be offered to the victim of sexual assault.

EE,ethynyl estradiol;P, progestin (levonorgestrel).

*If victim unvaccinated.

**If substantial exposure risk.

Sexual assault leads to a variety of acute emotional reactions ranging from severe distress to numbing of emotions, anger, and denial. There is no universal reaction. Medical providers should emphasize that the victim is not to blame. After the assault, a rape-trauma syndrome frequently occurs. This syndrome is characterized by an acute disorganized phase, then a delayed phase of organization. The acute phase lasts days to weeks and is characterized by physical reactions such as body aches, alterations of appetite and sleeping, and a variety of emotional reactions including anger, fear, anxiety, guilt, humiliation, embarrassment, self-blame, and mood swings. The later phase occurs in the weeks to months following and is characterized by flashbacks, nightmares, and phobias as well as somatic and gynecologic symptoms. Victims of sexual assault are at increased risk for post-traumatic stress disorder, major depression, and contemplation of suicide, or actual suicide attempt.

Rape survivors are also at increased risk for some chronic medical problems including chronic pelvic pain, fibromyalgia, and functional gastrointestinal disorders. It is important to consult with social workers and rape crisis counselors to provide immediate intervention, evaluate future emotional and safety needs, and to ensure proper follow-up. Rape crisis centers can provide ongoing support to victims and a list of these types of resources should be provided. In some centers, a sexual assault nurse examiner (SANE) who is extensively trained in this area is not only responsible for examining the victim and collecting evidence, but also can offer support and community referrals. Close follow-up is important not only for psychological support, but also to ensure that all vaccine schedules are followed, as well as to repeat STI testing at appropriate intervals.

Elder Abuse

Elder abuse is a widespread issue that impacts the well-being of approximately 1 in 10 adults over age 60, with an estimated 4 million older affected per year in the United States. Elder abuse can be physical, emotional, psychological, or sexual abuse, or many be in the form of neglect, abandonment, or financial exploitation. Contrary to common assumptions, most incidents of elder abuse does not happen in nursing homes or other institutional settings but usually take place at home and often the family, other household members, or paid caregivers are usually the abusers. Risk factors for elder abuse include cognitive impairment, depression and anxiety. There is no pathognomonic sign of elder abuse as signs can vary and may be subtle, and the majority of cases go undetected. It is important to screen all elderly women in order to identify victims and provide assistance.

Figure 31–2. Algorithm for evaluation and treatment of possible nonoccupational HIV exposures

(CDC 2015 STD Guideline Reference).

A detailed social history can evaluate family structure, stability of social supports, identify financial stressors, and substance abuse or mental health history. Patients reporting high levels of stress, depression, or anxiety, sleeping or eating difficulties may be the victims of abuse. Special attention should be paid to a history of multiple falls, frequent emergency room visits or hospitalizations, or difficulty controlling chronic medical problems as these may indicate an unstable social or family structure and possibly abuse. Poor hygiene, weight loss, unkempt appearance, missing assistive devices, and inappropriate attire may be some signs of neglect. Most states mandate that health care providers report confirmed cases to Adult Protective Services so it is important to educate yourself on the laws in your state. Elder abuse comes in many forms but the effects are the same. Abuse creates potentially harmful situations and feelings of worthlessness, and isolates the elder person from those who can help.

Intimate Partner Violence

Intimate partner violence occurs in every culture, country, and age group, and affects individuals in all socioeconomic and religious backgrounds. It takes place in same sex as well as heterosexual relationships. According to a 2007 CDC report, 22% of women are physically assaulted by a partner or date during their lifetime, and nearly 25% of women have been raped and/ or physically assaulted by an intimate partner at some time. Between 4% and 8% of pregnant women experience physical assault; thus, the CDC and ACOG recommend universal screening each trimester and postpartum. Lifelong consequences exist including physical impairment, emotional trauma, chronic health problems, and even fatality. Alcohol and/ or substance abuse is much more prevalent in women who are victims as well as men who commit violent acts.

Because of the high prevalence, the ob/ gyn physician must be particularly attuned to this problem. Sensitive, confidential, but direct questioning is the best approach: “Are you being hurt or threatened by anyone?” or “Do you feel safe at home?” It is paramount to assess lethality such as threats of homicide or suicide, abuse involving severe violence, use or and/ or access to weapons, pregnancy, or a recent separation. When homicide or child abuse is suspected, it is mandatory to notify the authorities.

It must be reinforced to a victim of domestic abuse that they are not responsible for the abuse, and should be empowered to learn about the resources and support services, needs to make their own decisions, and discussions held in confidentiality (to the limits of the law). A safety plan may be discussed including packing a bag in advance, having personal documents ready, having an extra set of car/ house keys, establishing a code with friends/ family, and having a plan of where to go. They may agree to speak to a social worker or someone at the National Domestic Violence Hotline (1-800-799-SAFE [7233]). Nevertheless, even if the patient denies intimate partner violence, it is beneficial to discuss the issues in a caring manner and offer educational material.

COMPREHENSION QUESTIONS

31.1 A 22-year-old female college student is sexually assaulted by an unknown male assailant. Penile-to-vaginal intercourse occurred and the patient states she does not believe a condom was used. The patient is not using any form of birth control and is not sexually active. Prior to prescribing emergency contraception, which of the following is most important to order?

A. Chlamydia assay

B. Pregnancy test

C. Serum alcohol level

D. HIV test

E. Liver function tests

31.2 An 82-year-old woman is being seen for her annual well woman examination. She is brought in by her middle-aged son via wheelchair. The patient has advanced dementia and cannot give a history, but her son says there have been no problems. On examination, you note that the patient is unkempt in appearance. Her BP is 140/ 85 mmHg and HR is 90 bpm. There are multiple bedsores on the sacral and back area. The patient has a diaper on. A red rash is noted on the introital region, and also some bruising on the vulvar and perineal area. Which of the following is the most likely diagnosis?

A. Behcet’s disease

B. Chronic alcoholism

C. Elder abuse

D. Lichen sclerosis

E. Squamous cell carcinoma

31.3 A third year medical student is doing research into intimate partner violence in pregnancy. Which of the following statements is most accurate?

A. Although violence does occur against pregnant women, homicide is rare.

B. The CDC recommends screening of intimate partner violence once during the pregnancy, usually at the first prenatal visit.

C. Intimate partner violence can lead to preterm delivery and low birth weight.

D. Usually intimate partner violence lessens during pregnancy due to concern about hurting the fetus.

31.4 A 28-year-old G1P1 woman is the victim of sexual assault. She has recently immigrated to the country and has not been vaccinated against hepatitis B. The assailant is unknown and his hepatitis B status is unknown. Which of the following is best management of the patient?

A. Administer HBIG only

B. Administer the hepatitis B vaccine only

C. Administer both HBIG and the hepatitis B vaccine

D. Expectant management since the hepatitis B status is unknown

ANSWERS

31.1 B. Prior to emergency contraception (EC), it is vital to assess an immediate pregnancy test, even for those patients who state that they are not sexually active or have never been sexually active. Because the EC may have a deleterious effect on any current pregnancy, a pregnancy test is mandatory.

31.2 C. An elderly patient who has dementia is at risk for elder abuse, because they have high needs and also cannot report the abuse. This patient has signs of neglect such as bedsores and unkempt appearance, and likely prolonged soiling without diaper changes. The vulvar bruising is highly suggestive of sexual abuse. Notification of the authorities is mandatory in a situation such as this.

31.3 C. Intimate partner violence increases in pregnancy and can lead to preterm delivery, low birth weight, and placental abruption. Homicide, usually in the first trimester, is the second leading cause of injury-related deaths to pregnant women after motor vehicle accidents. ACOG and the CDC recommends universal screening at the first prenatal visit and also each trimester and also postpartum.

31.4 C. After a sexual assault, hepatitis B immune globulin (HBIG) and the vaccine should be given if the assailant is thought to be hepatitis B positive and the patient has not been vaccinated previously. In a situation when the status of the assailant is unknown, the usual practice is still HBIG for any acute exposure, and then hepatitis B vaccination for longer term immunity.

    CLINICAL PEARLS    

» The most common type of rape are date rape and acquaintance rape. » It is important to screen for sexual assault at every visit. » Sexual assault is a traumatic experience and allowing the patient to dictate the order of events at evaluation is important. » Emergency contraception is most effective if given within the first 72 hours from the assault. » Post-exposure prophylaxis is indicated to cover C. trachomatis, N. Gonorrhea, T. vaginalis, and hepatitis B. » If not comfortable with the initial exam and specimen collection, contact a provider who is in order to ensure property evidence handling. » Repetitive visits, falls, and poor control of medical conditions may be signs of elder abuse. » Intimate partner violence (IPV) is common and is best screened by sensitive and direct questioning. » Mandatory reporting is required in situations where impending homicide or child abuse is suspected.

REFERENCES

American College of Obstetricians and Gynecologists. Intimate partner violence. ACOG Committee Opinion 518, 2012. 

American College of Obstetricians and Gynecologists. Emergency contraception. Practice Bulletin No. 112. Obstet Gynecol. 2010;115:1100-1109. 

American College of Obstetricians and Gynecologists. Elder abuse and women’s health. Committee Opinion No. 568. Obstet Gynecol. 2013;122:187-191. 

American College of Obstetricians and Gynecologists. Reproductive and sexual coercion. Committee Opinion No. 554. Obstet Gynecol. 2013;121:411-415. 

American College of Obstetricians and Gynecologists. Sexual assault. Committee Opinion No. 592. Obstet Gynecol. 2014;123:905-909. 

Centers for Disease Control and Prevention. The National Intimate Partner and Sexual Violence Survey; 2013a. Available at: cdc.gov/ violenceprevention/ nisvs; Accessed 23.07.2015. 

Federal Bureau of Investigation. Summary Reporting System (SRS) User Manual, version 1.0. Criminal Justice Information Services (CJIS) Division, Uniform Crime Reporting (UCR) Program. DC: FBI; 2013. Available at: http:/ /www.fbi.gov/ about-us/ cjis/ ucr/ nibrs/ summary-reporting-systemsrs- user-manual; Accessed 30.07.2015. 

Hoffman BL, Schorge JO, Schaffer JI, et al. Psychosocial issues and female sexuality. In: Hoffman BL, Schorge JO, Schaffer JI, eds. Williams Gynecology; New York: McGraw-Hill 2012, Chap. 13,2e. 

Linden JA. Clinical practice. Care of the adult patient after sexual assault. N Engl J Med. 2011;365: 834-841. 

Lu MC, Lu JS, Halfin VP. Domestic violence &sexual assault. In: DeCherney AH, Nathan L, Laufer N, Roman AS, eds. Current Diagnosis & Treatment: Obstetrics & Gynecology; 2013, Chap. 60, 11e. 

Richardson AR, Maltz FN. Ulipristal acetate: review of the efficacy and safety of a newly approved agent for emergency contraception. Clin Ther. 2012;34:24-36.

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