15. Sexual Abuse (Sexual Assault emergency med)

Question 1

Describe epidemiology: Sexual Assault (1)

Answer 1

1 in 5 women and 1 in 71 men will be sexually assaulted in their lifetime; only 7% are reported

Question 2

Describe general approach: Sexual Assault (7)

Answer 2

• ABCs, treat acute, serious injuries; physician priority is to treat medical issues and provide clearance
• ensure patient is not left alone and provide ongoing emotional support
• obtain consent for medical exam and treatment, collection of evidence, disclosure to police (notify police as soon as consent obtained)
• Sexual Assault Kit (document injuries, collect evidence) if <72 h since assault
• label samples immediately and pass directly to police
• offer community crisis resources (e.g. shelter, hotline)
• do not report unless victim requests or if <16 yr old (legally required)

Question 3

Describe history: Sexual Assault (5)

Answer 3

• ensure privacy for the patient – others should be asked to leave
• questions to ask: who, when, where did penetration occur, what happened, any weapons, or physical assault?
• post-assault activities (urination, defecation, change of clothes, shower, douche, etc.)
• gynecologic history
  
  • gravidity, parity, last menstrual period
  • contraception use
  • last voluntary intercourse (sperm motile 6-12 h in vagina, 5 d in cervix)
• medical history: acute injury/illness, chronic diseases, psychiatric history, medications, allergies, etc

Question 4

Describe physical exam: Sexual Assault (4)

Answer 4

• never re-traumatize a patient with the examination
• general examination
  
  • mental status
  • sexual maturity
  • patient should remove clothes and place in paper bag
  • document abrasions, bruises, lacerations, torn frenulum/broken teeth (indicates oral penetration)
• pelvic exam and specimen collection
  
  • ideally before urination or defecation
  • examine for seminal stains, hymen, signs of trauma
  • collect moistened swabs of dried seminal stains
  • pubic hair combings and cuttings
  • speculum exam
    
    • lubricate with water only
    • vaginal lacerations, foreign bodies
    • Pap smear, oral/cervical/rectal culture for gonorrhea and chlamydia
    • posterior fornix secretions if present or aspiration of saline irrigation
    • immediate wet smear for motile sperm
    • air-dried slides for immotile sperm, acid phosphatase, ABO group
• fingernail scrapings and saliva sample from victim

Question 5

Describe investigations: Sexual Assault (3)

Answer 5

• Venereal Disease Research Lab (VDRL): repeat in 3 mo if negative
• serum β-hCG
• blood for ABO group, Rh type, baseline serology (e.g. hepatitis, HIV)

Question 6

Describe management: Sexual Assault (3)

Answer 6

• involve local/regional sexual assault team (sexual assault forensic examiner or sexual assault nurse examiner)
• medical
  
  • suture lacerations, tetanus prophylaxis
  • gynecology consult for foreign body, complex lacerations
  • assume positive for gonorrhea and chlamydia
    
    • management: azithromycin 1 g PO x 1 dose (alt: doxycycline 100 mg PO bid x 10 d) and ceftriaxone 250 mg IM x 1 dose
  • may start prophylaxis for hepatitis B and HIV
  • pre and post counselling for HIV testing
  • pregnancy prophylaxis offered
    
    • levonorgestrel 1.5 g PO STAT (Plan B®)
• psychological
  
  • high incidence of psychological sequelae
  • have victim change and shower after exam completed

Question 7

Describe disposition: Sexual Assault (3)

Answer 7

• discharge if injuries/social situation permit
• follow-up with physician in rape crisis centre within 24 h for repeat pregnancy and STI testing.
• best if patient does not leave emergency department alone

Question 8

Describe: Domestic violence (4)

Answer 8

• women are usually the victims, but male victimization also occurs
• identify the problem (need high index of suspicion)
  
  • suggestive injuries (bruises, sprains, abrasions, occasionally fractures, burns, or other injuries; often inconsistent with history provided)
  • somatic symptoms (chronic and vague complaints)
  • psychosocial symptoms
  • clinician impression (your ‘gut feeling’, e.g. overbearing partner that won’t leave patient’s side)
• if disclosed, be supportive and assess danger
• patient must consent to follow-up investigation/reporting (unless for children)

Question 9

Describe management: Domestic violence (3)

Answer 9

• treat injuries and document findings
• ask about sexual assault and children at home (encourage notification of police)
• safety plan with good follow-up with family physician/social worker