Treatment of the Adult Victim of Sexual Assault

CHAPTER 157 Treatment of the Adult Victim of Sexual Assault



Olasunkanmi W. Adeyinka


Current statistics indicate that a sexual assault occurs every 4 seconds in this country. One in every four women will be sexually assaulted in her lifetime. But not only women are affected: almost 10% of assault victims are male. Sexual assault is the fastest-growing, most frequently committed, and most under-reported violent crime in the United States.


Sexual assault is under-reported for many reasons, including societal misconceptions about the victims of sexual assault, feelings invoked by such an assault, and the burden of reporting an assault. Misconceptions persist, despite enhanced public education, that individuals who are assaulted may have encouraged the act by their behavior, dress, lack of resistance, or previous promiscuity. Complex law enforcement and health care systems are often perceived as being impersonal and nonsupportive. An estimated 75% of victims know their perpetrators, possibly enhancing feelings of embarrassment, guilt, and fear of retribution. These feelings and misconceptions combined with inadequate support systems often prevent a victim from reporting a sexual assault.


The purpose of the medical evaluation after sexual assault is to assess the patient for physical injuries or possible disease, to document injuries, and to collect the necessary evidence. The remainder of the encounter should be used to treat any injuries, to prevent pregnancy and disease, and to find the proper support services for the victim. The examination and treatment should be completed as soon as possible after the assault, especially the collection of evidence. Although an evaluation within 48 hours is preferred, victims are encouraged to see a clinician even if more than 72 hours have elapsed (this still allows a clinician to treat and prevent many problems).


Collaboration between hospitals, community services, and local law enforcement agencies for the establishment of protocols is very helpful, and such protocols will ease victims’ pain and suffering. Primary care clinicians can be instrumental in ensuring that this collaboration takes place. Such collaboration is effective at not only streamlining the evaluation process but for easing the burden of reporting. Some institutions offer 24-hour availability of specially trained and experienced volunteers, such as a nurse on every shift. These volunteers can provide the victim continuous support during the cumbersome process of answering questions and the examination. They can also act as witnesses for the chain of evidence. A supportive volunteer system can offer such simple things as a change of clothing (victims often need to leave their clothing as evidence), which are hugely appreciated by victims.



Indication


Sexual assault requires treatment.


NOTE: Sexual assault is any form of nonconsenting sexual activity. It encompasses all unwanted sexual acts, from fondling to forcible penetration.



Contraindication


A lack of patient consent contraindicates treatment.



Equipment and Supplies



• Camera and film

• Wood’s light or other high wavelength light

• Sexual assault kit: Most emergency departments have a standard kit that contains a protocol for care and all the necessary specimen containers. These should be in compliance with and fulfill state laws for sexual assault (Table 157-1). In general, kits should contain the following:
• Information for the victim

• Consent form for the examination

• Instructions, checklist, and chain of custody form

• History and physical examination forms

• Diagrams for use in documentation of injuries (Fig. 157-1)

• Specimen containers, equipment, and labels

• Colposcope (optional)

TABLE 157-1 Sexual Assault Kit Equipment*



















































Contents Purpose
Two urine containers Urine for microscopic urinalysis, pregnancy test, and drug screen
Fingernail clippers, file, and envelope Fingernail clippings and scrapings
Forceps, scissors, two envelopes Pubic hair trimming in one envelope, head hair trimming in other envelope
Plastic comb, large paper towel, two envelopes Pubic hair combing in one envelope, head hair combing in other envelope
Vaginal speculum, aspiration pipette, red-topped test tube and stopper Aspiration of vaginal contents
Four cotton-tipped swabs and a test tube or envelope, one slide Vaginal (or penile) swabbing, and smear (same for rectal swabbing and smear if indicated)
Saline, 10 mL; two aspiration pipettes and bulbs; two test tubes, two slides Vaginal washing (and rectal if indicated using second pipette and test tube)
Cervical scraper, brush, slides, Pap smear fixative Pap smear
Thayer-Martin plates and Chlamydia cultures and/or sample tubes for gonorrhea/Chlamydia enzymatic probes Gonorrhea and Chlamydia evaluation (positive cultures are the gold standard for court, but probes have greater sensitivity)
Four cotton-tipped swabs and a test tube or envelope, one slide Oral swabs and smear
Two cotton-tipped swabs and a test tube or envelope Saliva collection for secretor status
Three red-topped test tubes and stoppers, tourniquet, nonalcohol swab to prepare skin, syringe and needle Blood samples
Labeled paper bags Collection of clothing and dried body fluids
Necessary and helpful forms Information, consent, and documentation

Patient education handout

Consent form

History and physical examination form

Diagrams for documentation of injuries

Chain of custody form

Any necessary instructions

Checklist
  

* Contents should be refrigerated after collection.


image

Figure 157-1 Traumagram. Mark and label locations where there is evidence of trauma.


(From Botasch AS, Braen GR, Gilchrist VJ: Acute care for sexual assault victims. Patient Care 28:112–137, 1994. Copyright Marcia Hartsock, Artist.)



Preprocedure Patient Education


If a patient calls before presenting to the emergency department, first make sure that the patient is safe. If not, encourage the patient to call the police. Next, encourage the patient not to take a bath or remove the clothing worn during the assault. If possible, they should postpone urinating, defecating, brushing their teeth, or drinking anything until samples are collected. Also, ask them to bring a change of clothing. Patients should sign for informed consent before starting the evaluation (see the patient consent form available online at www.expertconsult.com).


Explain the process of the evaluation to patients. Let them know that you will explain every step of the examination before performing it. Even if they may not want to report the assault, a very thorough examination is necessary in case of a later change of mind. Continue to reassure patients that they are safe and that someone else will always be in the room to comfort them during the evaluation.



Procedure



1 Open the sexual assault kit. Once the kit is opened, the chain of evidence must be maintained and evidence must not be left unattended. Signatures of those in attendance must be documented on the form for any and all evidence collected. (See Chapter 158, Management of the Young Female as a Possible Victim of Sexual Abuse, Fig. 158-8, for a sample chain of evidence form.) The kit should be labeled as a biohazard. After the patient has signed the consent form, proceed with taking the history.


History



2 The history should be taken in a quiet room, with a witness present, after the patient has been assured that she or he is safe. Be cautious about the terms used in stating patient complaints. Avoid use of the word “rape” because this is a legal term. Instead, state the patient complaint as being a “sexual assault.” Also, try to avoid the phrases “why didn’t you …” or “you shouldn’t have …” or “Did you do anything to lead them on?” In fact, try to avoid the words “why” and “alleged” altogether; “why” implies blame and “alleged” implies disbelief.

Questions should be directed to the victim in a nonjudgmental way, and the patient should be allowed to talk about the assault at a comfortable pace, using her or his own words. It is important to observe nonverbal communication that may indicate a need for further questioning. Supportive terms worth using include “I’m glad you’re alive,” “You did what you needed to survive,” “I’m sorry this happened to you,” and “It was not your fault.” Allow the victim to express her or his feelings. To build rapport, it may be worth obtaining the medical and sexual history before obtaining the assault history.

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Treatment of the Adult Victim of Sexual Assault

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