Rape/Sexual Assault

1. Provide comprehensive care to all patients who have been sexually assaulted, regardless of their decision to proceed with evidence collection or not.
2. Apply the same principles of managing sexual assault in the acute setting to other ambulatory settings (i.e. medical assessment, pregnancy prevention, STI screening/treatment/prophylaxis, counselling).
3. Limit documentation in sexual assault patients to observations and other necessary medical information (i.e., avoid recording hearsay information).
4. In addition to other post-exposure prophylactic measures taken, assess the need for human immunodeficiency virus and hepatitis B prophylaxis in patients who have been sexually assaulted.
5. Offer counselling to all patients affected by sexual assault, whether they are victims, family members, friends, or partners; do not discount the impact of sexual assault on all of these people.
6. Revisit the need for counselling in patients affected by sexual assault.
7. Enquire about undisclosed sexual assault when seeing patients who have symptoms such as depression, anxiety, and somatization

General Overview

• 50-80% of sexual assaults from acquaintance (friend, family)
• Care includes legal, medical, psychosocial
• Consider referral
  • Availability of another site for assessment (sexual assault center)
  • Time available to complete evaluation
  • Experience with evaluation and treatment
  • Ability to collect and preserve appropriate evidence
• May present as psychiatric complaint (anxiety/depression/eating disorder), suicidal ideation, sexual dysfunction, fatigue, GI complaints, insomnia, pelvic pain, chronic pain

History

• Record patient's exact words
• Use phrases "alleged sexual assault, or sexual assault by history"
  • Avoid using the word "rape" as this is a legal (not medical) term
• Document identifying information about patient and assailant
  • Date, time, location, circumstances of assault (sexual contact, exposure to bodily fluids)
  • Note what the patient did after the assault (washing, changing clothes)
• Document use of restraints (weapons, drugs, alcohol)
• Gynecological history (contraception, pregnancy, most recent consensual sexual encounter)

Physical Examination

• Consent from survivor for each step of examination
• Examine entire body
• Sexual assault kit if <5 days
• Consider drug facilitated sexual assault if amnesia
  • Alcohol is the most common substance associated with sexual assault
  • Chloral hydrate, Gamma hydroxybuterate, ketamine, benzodiazepines are detected in urine up to 72h

Investigation

• Urine and Serum B-hCG
• STI screen
  • HIV
  • Syphilis EIA or RPR
  • Gonorrhea and chlamydia PCR
  • HBsAg, HepBsAb
• Optional
  • Wet mount/culture for trichomoniasis vaginalis
  • HCV (consider in high risk, IVDU)

Management

• ABC, rule-out major trauma
• Emergency contraception to all women with negative pregnancy test (~5% risk of pregnancy)
  • Copper IUD - failure rate of <1% (>95% effective)
  • Ulipristal acetate 30mg PO x1 - failure rate of 1.4% (~75% effective) up to 120h
  • Levonorgestrel 1.5 mg PO x1 (or 0.75mg q12h x2) - failure rate of 2.2% (~50% effective) up to 72h (proven efficacy up to 96h, limited efficacy up to 120h)
• Hepatitis B vaccine (if not immune)
  • HBV vaccine at 0, 1, 6 months if non-immune
  • If high risk and non-immune (or unknown) may consider HBIG 0.06mL/kg x 1 within 14d
• HIV prophylaxis
  • Discuss low seroconversion rates
    • Known HIV positive after one exposure in consensual (number not unknown in non-consensual)
      • Receptive oral 0.01%, vaginal 0.1%, anal 0.5%
    • If unknown HIV positive, risk likely very low
  • Most effective within 2h after exposure, and not offered 72h unless assailant known HIV positive
    • Emtricitabine / tenofovir (Truvada) 200/300mg PO daily AND raltegravir (Isentress) 400mg PO BID X 28 days
• Prophylaxis for gonorrhea, chlamydia, trichomoniasis
  • Cefixime 800mg PO x1, Azithromycin 1g PO x1, Metronidazole 2g PO x1
• Psychological support, and counselling
• Close and periodic long-term follow-up
  • Follow-up testing 2w, 6w, 3mo, 6mo
    • Gonorrhea/Chlamydia repeat at 1-2w if prophylaxis not offered
    • Syphilis repeat at (6w), 3mo, 6mo
    • HIV repeat at 6w, 3mo, 6mo
  • Consider closer follow-up at 1-2w if no prophylaxis taken to repeat STI screen